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In navigating the complexities of securing workers' compensation insurance, businesses are often required to complete an Acord 130 form, a comprehensive document that serves as the workers' compensation application. This form gathers detailed information about the company seeking insurance, including its name, contact information, type of business entity, years in operation, and industry classification codes like SIC and NAICS. Additionally, it delves into the specific nature of the business operations, types of work performed, and the use of subcontractors, which helps underwriters assess the risk and determine the appropriate premium. Other critical sections of the form address the company's loss history, any other insurance coverage in place, and specific requirements or options related to the workers' compensation insurance policy like deductible amounts, states of operation, and special coverage options. Employers must also disclose any relevant financial issues such as tax liens or bankruptcies, compliance with safety and health regulations, and the employment of minors or workers with physical handicaps. The form even touches upon the applicant's credit information, as it can influence the terms of the insurance offered. Completing this form accurately is crucial for businesses to ensure they are adequately covered and compliant with state workers' compensation laws.

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WORKERS COMPENSATION APPLICATION

DATE (MM/DD/YYYY)

 

 

 

AGENCY NAME AND ADDRESS

 

 

 

 

COMPANY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNDERWRITER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE PHONE:

 

 

 

 

 

 

 

 

 

 

MOBILE PHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code)

YRS IN BUS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIC:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRODUCER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAICS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CS REPRESENTATIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WEBSITE

 

 

 

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS:

 

 

 

OFFICE PHONE

 

 

 

 

 

 

 

 

 

 

E-MAIL ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(A/C, No, Ext):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOBILE

 

 

 

 

 

 

 

 

 

 

 

 

 

SOLE PROPRIETOR

 

 

CORPORATION

 

LLC

 

 

 

 

 

TRUST

 

 

 

UNINCORPORATED

PHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSOCIATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBCHAPTER

 

 

 

 

 

 

 

 

 

 

 

 

 

FAX

 

 

 

 

 

 

 

 

 

 

 

 

 

PARTNERSHIP

 

 

 

JOINT VENTURE

 

 

 

OTHER:

 

 

 

(A/C, No):

 

 

 

 

 

 

 

 

 

 

 

 

 

"S" CORP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL

 

 

 

 

 

 

 

 

 

 

 

 

CREDIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID NUMBER:

 

 

 

ADDRESS:

 

 

 

 

 

 

 

 

 

 

BUREAU NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODE:

 

 

 

 

 

 

SUB CODE:

 

 

FEDERAL EMPLOYER ID NUMBER

 

 

NCCI RISK ID NUMBER

 

 

 

OTHER RATING BUREAU ID OR STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER REGISTRATION NUMBER

AGENCY CUSTOMER ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF SUBMISSION

 

BILLING / AUDIT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUOTE

 

 

 

ISSUE POLICY

 

BILLING PLAN

 

PAYMENT PLAN

 

 

 

 

 

 

 

 

 

 

 

 

AUDIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BOUND (Give date and/or attach copy)

 

 

AGENCY BILL

 

 

ANNUAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AT EXPIRATION

 

 

MONTHLY

 

ASSIGNED RISK (Attach ACORD 133)

 

 

DIRECT BILL

 

 

SEMI-ANNUAL

 

 

 

 

 

 

 

 

 

 

 

 

SEMI-ANNUAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUARTERLY

 

 

% DOWN:

 

 

 

 

 

 

 

QUARTERLY

 

 

 

LOCATIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOC #

HIGHEST

 

STREET, CITY, COUNTY, STATE, ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FLOOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPOSED EFF DATE

 

 

PROPOSED EXP DATE

 

 

NORMAL ANNIVERSARY RATING DATE

 

 

PARTICIPATING

 

 

 

 

RETRO PLAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-PARTICIPATING

 

 

 

 

 

 

 

 

PART 1 - WORKERS

PART 2 - EMPLOYER'S LIABILITY

 

 

 

 

 

PART 3 - OTHER

 

 

DEDUCTIBLES

 

 

 

 

AMOUNT / %

OTHER COVERAGES

 

 

 

 

 

 

 

 

 

 

(N / A in WI)

 

 

 

 

 

 

COMPENSATION (States)

 

 

 

 

 

STATES INS

 

 

 

 

 

(N / A in WI)

 

 

 

 

 

 

 

 

 

$

 

 

 

EACH ACCIDENT

 

 

 

 

 

MEDICAL

 

 

 

 

 

 

U.S.L. & H.

 

 

MANAGED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CARE OPTION

 

 

 

 

 

 

$

 

 

 

DISEASE-POLICY LIMIT

 

 

 

 

 

 

 

 

 

 

INDEMNITY

 

 

 

 

 

 

 

 

VOLUNTARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMP

 

 

 

 

 

 

 

 

 

$

 

 

 

DISEASE-EACH EMPLOYEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOREIGN COV

 

 

 

DIVIDEND PLAN/SAFETY GROUP

 

ADDITIONAL COMPANY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES

TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES

TOTAL MINIMUM PREMIUM ALL STATES

TOTAL DEPOSIT PREMIUM ALL STATES

$

$

$

 

 

 

CONTACT INFORMATION

TYPE

NAME

OFFICE PHONE

MOBILE PHONE

E-MAIL

 

 

 

 

 

INSPECTION

 

 

 

 

 

 

 

 

 

ACCTNG

 

 

 

 

RECORD

 

 

 

 

CLAIMS

 

 

 

 

INFO

 

 

 

 

INDIVIDUALS INCLUDED / EXCLUDED

PARTNERS, OFFICERS, RELATIVES ( Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.

STATE

LOC #

NAME

DATE OF BIRTH

TITLE/

OWNER-

DUTIES

INC/EXC

CLASS CODE

REMUNERATION/PAYROLL

RELATIONSHIP

SHIP %

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACORD 130 (2013/01)

Page 1 of 4

© 1980-2013 ACORD CORPORATION. All rights reserved.

 

The ACORD name and logo are registered marks of ACORD

STATE RATING SHEET #

 

OF

 

SHEETS

AGENCY CUSTOMER ID:

STATE RATING WORKSHEET

FOR MULTIPLE STATES, ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM RATING INFORMATION - STATE:

LOC # CLASS CODE

DESCR

CODE

CATEGORIES, DUTIES, CLASSIFICATIONS

# EMPLOYEES

FULL PART

TIME TIME

SIC

NAICS

ESTIMATED ANNUAL

REMUNERATION/

PAYROLL

ESTIMATED

RATE ANNUAL MANUAL PREMIUM

PREMIUM

STATE:

FACTOR

FACTORED PREMIUM

 

FACTOR

FACTORED PREMIUM

TOTAL

N / A

$

 

 

$

INCREASED LIMITS

 

$

SCHEDULE RATING *

 

$

DEDUCTIBLE *

 

$

CCPAP

 

$

 

 

$

STANDARD PREMIUM

 

$

EXPERIENCE OR MERIT

 

$

PREMIUM DISCOUNT

 

$

MODIFICATION

 

 

 

 

$

EXPENSE CONSTANT

N / A

$

ASSIGNED RISK SURCHARGE *

 

$

TAXES / ASSESSMENTS *

N / A

$

ARAP *

 

$

 

 

$

* N / A in Wisconsin

 

 

 

 

 

TOTAL ESTIMATED ANNUAL PREMIUM

$

MINIMUM PREMIUM

$

DEPOSIT PREMIUM

$

REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

 

 

ACORD 130 (2013/01)

Page 2 of 4

PRIOR CARRIER INFORMATION / LOSS HISTORY

AGENCY CUSTOMER ID:

PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS

 

 

 

LOSS RUN ATTACHED

 

YEAR

CARRIER & POLICY NUMBER

ANNUAL PREMIUM

MOD

# CLAIMS

AMOUNT PAID

RESERVE

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

POL #:

NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS

GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING - RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT; CONTRACTOR - TYPE OF WORK, SUB-CONTRACTS; MERCANTILE - MERCHANDISE, CUSTOMERS, DELIVERIES; SERVICE - TYPE, LOCATION; FARM - ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS.

GENERAL INFORMATION

EXPLAIN ALL "YES" RESPONSES

1.DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?

2.DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)

3.ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?

4.ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?

5.IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?

6.ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)

7.ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If "YES", payroll for this work must be included in the State Rating Worksheet on Page 2)

8.IS A WRITTEN SAFETY PROGRAM IN OPERATION?

9.ANY GROUP TRANSPORTATION PROVIDED?

10.ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?

11.ANY SEASONAL EMPLOYEES?

12.IS THERE ANY VOLUNTEER OR DONATED LABOR? (If "YES", please specify)

13.ANY EMPLOYEES WITH PHYSICAL HANDICAPS?

14.DO EMPLOYEES TRAVEL OUT OF STATE? (If "YES", indicate state(s) of travel and frequency)

15.ARE ATHLETIC TEAMS SPONSORED?

Y / N

ACORD 130 (2013/01)

Page 3 of 4

(Applicant's Initials):

GENERAL INFORMATION (continued)

AGENCY CUSTOMER ID:

EXPLAIN ALL "YES" RESPONSES

16.ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?

17.ANY OTHER INSURANCE WITH THIS INSURER?

18.ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)

19.ARE EMPLOYEE HEALTH PLANS PROVIDED?

20.DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?

21.DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

22.DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If "YES", # of Employees:

23.ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (If "YES", please specify)

24.ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).

Y / N

SIGNATURE

Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)

PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.

(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.)

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).

Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

Applicable in Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company, Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).

Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Applicable in Utah: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

APPLICANT'S SIGNATURE (Must be Officer, Owner or Partner)

DATE

PRODUCER'S SIGNATURE

NATIONAL PRODUCER NUMBER

ACORD 130 (2013/01)

Page 4 of 4

File Attributes

Fact Name Detail
Form Purpose The ACORD 130 form is used for the application of workers' compensation insurance.
Applicant Information It collects detailed information about the applicant, including the name, contact details, business type, and federal employer identification number.
Business Information The form requests specific data about the business, such as years in operation, SIC/NAICS codes, and information regarding locations and operations.
Policy Details Details about the requested workers' compensation policy, including effective dates, coverage parts, states insured, and premium calculations, are included on the form.
Governing Laws While the ACORD 130 form is generally standardized, certain sections must comply with state-specific workers' compensation laws and regulations where applicable.

How to Fill Out Acord 130

Filling out the Acord 130 form is a necessary step for securing workers compensation insurance. This document asks for detailed information about your business, including its operations, employee details, and your insurance needs. Taking the time to accurately complete each section ensures that your insurance coverage matches your business’s specific requirements, helping to protect both you and your employees. Follow these steps meticulously to ensure the form is filled out correctly and completely.

  1. Enter the date in the format MM/DD/YYYY at the top of the form.
  2. Fill in the agency name and address, including the company and underwriter if known.
  3. Provide the applicant name, which is the legal name of your business.
  4. Add the office and mobile phone numbers alongside the mailing address with ZIP + 4 or Canadian Postal Code.
  5. Indicate the years in business (YRS IN BUS), and include the Standard Industrial Classification (SIC) and North American Industry Classification System (NAICS) codes.
  6. List the producer name, CS representative, and website, along with contact details.
  7. Select the type of business entity (sole proprietorship, corporation, LLC, etc.).
  8. Provide your Credit ID number, Bureau name, and any applicable codes, including the Federal Employer ID Number (FEIN).
  9. Under Status of Submission, note whether the form is for a quote, issue, policy, or other statuses and fill in the billing/audit information accordingly.
  10. Specify the location(s) of your business, including the highest floor if applicable.
  11. Detail the policy information including proposed effective and expiration dates, coverage parts, and deductibles if any.
  12. For additional company information, specify any endorsements or coverages not included in the main form and the total estimated annual premium.
  13. Include contact information for inspections, accounting, and claims, clearly indicating if any individuals are to be included or excluded from coverage.
  14. Fill out the State Rating Worksheet if your business operates in multiple states, ensuring to provide detailed information on your operations and payroll in each location.
  15. If applicable, provide prior carrier information and loss history for the past 5 years to assist in accurately assessing your risk and premium.
  16. Describe your nature of business/operations in detail to give underwriters a clear understanding of your business activities.
  17. Answer the questions in the General Information section, explaining all "Yes" responses as required.
  18. Ensure that the applicant's signature and the date are on the last page of the form, alongside the producer's signature and national producer number.

Once completed, review the form to ensure all information is accurate and complete. Submitting accurate and thorough information on the Acord 130 form is crucial for obtaining workers compensation insurance that adequately protects your business and meets legal requirements.

Frequently Asked Questions

What is the Acord 130 form used for?

The Acord 130 form is a workers compensation application used in the United States. It collects information necessary for an insurance underwriter to provide a quote for workers compensation insurance. This includes details about the business applying for insurance, like its name, address, the nature of its operations, and specific information about employees and payroll. Additionally, it gathers past loss history and other relevant information that affects the insurance premium.

Who needs to fill out the Acord 130 form?

Any business entity seeking to purchase workers compensation insurance needs to complete the Acord 130 form. This includes sole proprietors, partnerships, corporations, LLCs, and other business structures that employ workers and are required by state law to carry workers compensation insurance.

What information do you need to complete the form?

To fill out the Acord 130 form accurately, you will need:

  • Business information, including company name, address, and contact details.
  • Years in business and industry classification codes (SIC and NAICS).
  • Details on the business entity type (e.g., corporation, partnership).
  • Federal Employer ID Number and any applicable rating bureau ID numbers.
  • Information about payroll, employee roles, and remuneration.
  • Prior carrier information and loss history for the past five years.

Where do you submit the completed Acord 130 form?

Once completed, the Acord 130 form should be submitted to the insurance agency or broker handling the workers compensation insurance policy application. They will forward it to the underwriter for processing and quote development.

Can the information on the Acord 130 form affect premium rates?

Yes, the information provided on the Acord 130 form directly influences the calculation of premium rates for workers compensation insurance. Factors such as the nature of the business operations, payroll information, and loss history play significant roles in determining the risk level and consequently the insurance premium.

Is it necessary to answer every question on the form?

It is important to answer all applicable questions on the Acord 130 form as accurately and completely as possible. Missing or inaccurate information can delay the underwriting process, potentially affect coverage, and influence premium calculations.

What happens if there are changes to the information provided after submission?

If there are any changes to the information initially provided on the Acord 130 form after submission, it is crucial to notify the insurance company or agent immediately. Changes, especially those concerning employment numbers, payroll, or business operations, can impact coverage and premiums.

Does completing the Acord 130 form guarantee insurance coverage?

No, completing and submitting the Acord 130 form does not guarantee insurance coverage. It is the first step in the application process for workers compensation insurance. Coverage is determined after review and underwriting by the insurance carrier, which may involve additional questions or requests for information.

Common mistakes

Filling out the Acord 130 form for workers compensation insurance is a crucial step for businesses, but it's easy to make mistakes that can delay or impact coverage. Understanding these common mistakes can help ensure that your application is completed accurately, providing the protection your business needs.

One of the most common mistakes is not providing accurate business information. The form requires specifics, such as the full legal name of the business, mailing address, and federal employer identification number (FEIN). Businesses sometimes enter incorrect or incomplete information. Ensuring that all details are accurate and match official documents is essential for a smooth application process.

Another area often filled out incorrectly is the description of operations section. Clearly and comprehensively detailing the nature of your business and the work performed is crucial. Generic or vague descriptions can lead to incorrect classifications, potentially affecting coverage and premiums. Be specific about your business activities, materials used, and the services provided to get the correct classification.

Incorrectly identifying the number of employees or misclassifying them as full-time or part-time can also create issues. This information directly affects your premium calculations and coverage. Ensure that employee counts are accurate and reflect your current workforce correctly.

Applicants sometimes forget to include all locations where they operate. Each physical location where your business operates must be listed on the form. Failing to disclose all locations can lead to inadequate coverage if an incident occurs at an unreported location.

Another mistake is underreporting payroll or misclassifying workers. Your workers' compensation premium is based partly on your payroll, and inaccuracies here can lead to incorrect premiums. Additionally, misclassifying workers—such as listing an employee as an independent contractor—can lead to significant issues with your coverage.

The details regarding prior insurance coverage and loss history must also be accurate and comprehensive. Omitting information about past claims or previous insurers can be seen as fraudulent and might impact your ability to obtain coverage. Ensure that all information provided about your loss history and previous policies is complete and accurate.

Lastly, not reviewing the completed form for accuracy and completeness is a critical mistake. Once you think you've filled the form correctly, review each section to ensure no errors or omissions. An error as simple as a transposed phone number or a misspelled name can delay the processing of your application.

By paying careful attention to the details and avoiding these common mistakes, businesses can ensure a smoother application process for their workers' compensation insurance. Accurate, complete, and clear information is key to obtaining the right coverage for your business needs.

Documents used along the form

When businesses apply for workers' compensation insurance using the Acord 130 form, they are often required to submit additional documents alongside it. These documents provide more detailed information about the business, its operations, and its employees, helping insurers to better assess the risks and calculate premiums. Let's look at four commonly requested forms and documents that accompany the Acord 130 form.

  • ACORD 125 - Commercial Insurance Application: This form gathers general information about the business seeking insurance. It covers the nature of the business, its history, and specific details about its operations, which are essential for underwriters to evaluate the overall risk profile of the company.
  • ACORD 126 - General Liability Application: For businesses that require general liability coverage in addition to workers' compensation, this form collects data relevant to assessing liability risks. It details the types of operations the business performs, its products, and services, and any exposures that might lead to liability claims.
  • Loss Runs: These are reports generated by prior insurance providers that outline the history of claims made by the business. Loss runs help insurers understand the business's claim history, which is a critical component in determining future premiums and coverage terms.
  • Experience Modification Rating (EMR) Letter: An EMR is a number used by insurance companies to gauge both past cost of injuries and the future chances of risk. The lower the EMR of your business, the lower your worker compensation insurance premiums will be. This letter or document proves the EMR assigned to a business, based on its history of work-related injuries and claims.

Together with the Acord 130 form, these documents paint a full picture of a business’s risk level and insurance needs. They allow insurers to provide the most accurate quotes and ensure that businesses are adequately covered for their specific risks. It's important for businesses to prepare these documents carefully, as inaccuracies can lead to improper coverage or issues with claims down the line.

Similar forms

The Acord 130 form, primarily used for applying for workers compensation insurance, has similarities with several other insurance documents, each catering to different facets of insurance applications and claims. Among these, the first is the Business Owners Policy (BOP) Application. Like the Acord 130, the BOP Application is structured to collect detailed information about a business, including its operations, ownership, and risk exposures, to evaluate and underwrite insurance coverage. While the focus is broader than just workers compensation, covering property and liability insurance, the essence of gathering comprehensive information for risk assessment is a common thread.

Secondly, the Commercial Auto Insurance Application shares similarities with the Acord 130 form in terms of detailing operations and risk exposure. Both forms require information about the business and its operations, with the Commercial Auto Application focusing on vehicles owned and operated by the business. The details regarding use, drivers, and vehicle information are critical for underwriters to accurately assess the risk and determine premiums, paralleling the Acord 130's objective of capturing the necessary data for workers' compensation insurance.

Similarly, the General Liability Insurance Application is another document that resonates with the Acord 130 form. It focuses on assessing a business's liability risks and operational details to tailor liability coverage. Like the workers compensation form, it requires comprehensive information about the business, its practices, and potential exposure to liabilities, emphasizing the need for insurers to understand the extent of coverage required based on the business operations and the associated risks.

The Property Insurance Application also mirrors the Acord 130 in its purpose of risk assessment and insurance underwriting. By detailing the physical assets and potential risk factors of a business, insurers use the information provided to evaluate the insurance needs against possible property damage or loss. This parallels the Acord 130's goal of understanding the workforce and operations to underwrite suitable workers compensation insurance, highlighting the importance of detailed information for accurate risk evaluation.

Last but not least, the Employer's Liability Insurance Application is closely aligned with the Acord 130 form in its focus, albeit with a concentration on employer liability beyond the scope of workers compensation. This form collects information on the business and its operations to protect against liabilities arising from employee injury or disease that aren't covered under workers compensation. Both documents underscore the importance of capturing detailed business operations and risk exposures to tailor the insurance coverage appropriately, ensuring businesses are adequately protected against potential claims.

Dos and Don'ts

Filling out the Acord 130 form, an essential document for workers' compensation insurance, requires careful attention to detail and accuracy. To ensure that you complete this form correctly and avoid common pitfalls, here's a guide of things you should and shouldn't do:

  • Do ensure all information is accurate and up-to-date, reflecting the current status of your business and employees.
  • Do review the entire form before starting to fill it out, to understand what information is required and how it should be provided.
  • Do use the legal name and address of your business, avoiding any abbreviations or nicknames, to prevent confusion or delays in processing.
  • Do include all necessary attachments, such as the ACORD 101, Additional Remarks Schedule, for any information that requires further explanation or doesn’t fit in the provided spaces.
  • Do verify the classification codes and payroll estimates to ensure they accurately reflect your business operations and workforce.
  • Don't leave sections blank unless they truly do not apply to your business; if in doubt, provide the information with a note for clarification.
  • Don't estimate or guess when it comes to figures like payroll or revenue; use actual numbers from your records to provide accurate estimates.
  • Don't rush through the form to avoid errors that could delay processing or affect your coverage.
  • Don't hesitate to contact your insurance agent or broker if you have questions or need clarification on how to correctly fill out the form.

By following these guidelines, you can help ensure that your Acord 130 form is filled out correctly and efficiently, leading to a smoother insurance application process.

Misconceptions

When discussing the Acord 130 form, several misconceptions often arise due to its comprehensive nature and its pivotal role in workers' compensation insurance. Understanding these misconceptions is essential for ensuring accurate completion and submission of the form.

  • It’s only for Workers' Compensation: A common misconception is that the Acord 130 form is solely for workers' compensation insurance applications. While its primary use is for this purpose, it also encompasses information relevant to employer's liability and other coverages, making it a multi-faceted form essential for properly assessing risk and coverage needs.
  • One size fits all: Many believe once filled, the Acord 130 can be submitted to any insurance provider as a universal application. However, while it is a standardized form, specific insurers and states may require additional information or documentation. It is not a one-size-fits-all document; customization to meet specific underwriter or state requirements is often necessary.
  • Solely for Initial Applications: Another misconception is that the Acord 130 is only for initial insurance applications. In reality, this form may also be used for renewals or amendments to existing policies, ensuring all information is up-to-date and reflects any changes in operations or risk.
  • Completion Guarantees Coverage: Some believe that simply completing and submitting the Acord 130 guarantees coverage. This is not the case; insurers use the information provided to assess risk and determine eligibility for coverage. It initiates the underwriting process but does not assure acceptance or specific terms of insurance.
  • Personal Information is not Required: There is a misconception that personal information about the owners or officers of a company is not needed on the Acord 130. However, certain sections do require this information, particularly when it pertains to contact information or the identification of individuals who may be exempt from coverage. Accurate and thorough completion is crucial for proper assessment and compliance.
  • No Need for Detailed Job Descriptions: Finally, some think that providing general information about business operations is sufficient. Yet, the form requests detailed descriptions of operations, including the nature of the work performed, materials used, and processes involved. This detail is necessary for insurers to accurately determine the class codes for premium calculation and to assess any unique risks associated with specific job roles or operations.

Clarifying these misconceptions is crucial for agents, applicants, and all parties involved in the workers' compensation insurance process. Accurate and thorough completion of the Acord 130 form ensures that the underwriting process is based on comprehensive and correct information, leading to appropriately tailored coverage that meets the specific needs and risks of the business applying.

Key takeaways

Filling out the Acord 130 form, which is the Workers Compensation Application, is an important step for businesses seeking workers' compensation insurance. Below are seven key takeaways to guide you in completing and using this form effectively:

  • The Acord 130 form requires detailed business information, including the applicant's name, contact information, business type (e.g., sole proprietorship, LLC, corporation), and years in business. Ensure all information is current and accurate to avoid any processing delays.
  • Workers compensation laws and requirements can vary by state, making it crucial to understand and adhere to the specific regulations applicable to the state(s) where your business operates. This form accommodates multi-state operations, but additional paperwork may be required for each state.
  • The form requests information about your company’s operations, including the nature of the business, number of employees, estimated annual payroll, and details about your prior insurance coverage and loss history. This data helps in accurately assessing your insurance needs and premium.
  • Sections that require details about the business operations and employee roles are designed to identify any potential risks or specialized coverage requirements. Complete these sections thoughtfully, as they significantly influence the insurance company's offer and the policy's terms.
  • It is important to disclose any use of subcontractors and provide certificates of insurance for them if applicable. Failure to disclose this information can lead to uncovered claims or increased premiums.
  • Specific questions within the form aim to uncover any unique risks associated with your business, such as operations involving hazardous materials, work performed at significant heights, or any engagement in special types of work. Being upfront and detailed in these sections ensures appropriate coverage and helps avoid claim denials.
  • The applicant's declaration at the end of the Acord 130 form is a legal acknowledgment that all the information provided is accurate to the best of the applicant's knowledge. It's a reminder of the importance of thoroughness and honesty in the insurance application process. Any deliberate misinformation could be considered insurance fraud, leading to penalties or denial of coverage.

Completing the Acord 130 form is a critical step in securing workers' compensation insurance. It requires attention to detail and an understanding of your business operations to ensure you receive the most accurate coverage and premium estimates. Always consult with an insurance professional if you encounter any uncertainties during the application process.

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