The ACORD 130 form is a crucial document used to apply for workers' compensation insurance. It collects essential information about the applicant's business, including details on operations, employee classifications, and coverage needs. Completing this form accurately ensures that your business receives the appropriate coverage and support.
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The ACORD 130 form serves as a crucial tool for businesses seeking workers' compensation insurance. This application collects essential information about the applicant, including the agency's name, contact details, and the nature of the business operations. It prompts the applicant to provide details such as years in business, employee classifications, and payroll estimates. The form also addresses various coverage options, including employer's liability and additional endorsements. By gathering this information, the ACORD 130 enables insurers to assess risk accurately and determine appropriate premiums. Additionally, the form includes sections for loss history and prior carrier information, allowing insurers to evaluate the applicant's past claims and coverage. Understanding how to complete the ACORD 130 form accurately is vital for any business looking to secure the necessary protection for their employees and ensure compliance with state regulations.
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:
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
QUARTERLY
% DOWN:
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
$
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
MOBILE PHONE
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
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
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
TOTAL
N / A
INCREASED LIMITS
SCHEDULE RATING *
DEDUCTIBLE *
CCPAP
STANDARD PREMIUM
EXPERIENCE OR MERIT
PREMIUM DISCOUNT
MODIFICATION
EXPENSE CONSTANT
ASSIGNED RISK SURCHARGE *
TAXES / ASSESSMENTS *
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)
Page 2 of 4
PRIOR CARRIER INFORMATION / LOSS HISTORY
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 #:
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
Page 3 of 4
GENERAL INFORMATION (continued)
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).
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
Page 4 of 4
Completing the ACORD 130 form is an essential step in applying for workers' compensation insurance. This form collects necessary information about your business, including your operations, employee details, and coverage needs. Follow these steps carefully to ensure accurate and complete submission.
The Acord 130 form is a standardized application used for obtaining workers' compensation insurance. It collects essential information about a business, its operations, and its employees to help insurance companies assess risk and determine premiums.
Any business that seeks workers' compensation insurance must complete the Acord 130 form. This includes sole proprietors, corporations, partnerships, and LLCs. Essentially, if you employ individuals and want to protect them and your business from workplace injuries, this form is necessary.
The form requests various details, including:
The estimated annual premium is calculated based on several factors, including the type of business, the number of employees, their classifications, and the overall payroll. The insurance company will use this information to assess the risk associated with insuring your business.
If there are significant changes in your business operations, such as hiring more employees or changing the nature of your work, it's crucial to inform your insurance provider. These changes can impact your coverage and premium, and failing to report them could lead to complications down the line.
Yes, certain exclusions may apply based on your business type or the nature of your operations. For instance, some hazardous activities or specific employee classifications may not be covered. It’s essential to review the policy details and discuss any concerns with your insurance agent.
Subcontractors can be included, but their payroll must be reported on the Acord 130 form. Additionally, you may need to provide proof of their insurance coverage. This ensures that all parties involved in your business operations are adequately protected.
The loss history section provides the insurance company with insight into your past claims. This information is critical as it helps them evaluate the risk associated with insuring your business. A history of frequent claims may lead to higher premiums.
Once you have completed the Acord 130 form, submit it to your insurance agent or broker. They will review the information and forward it to the insurance company for processing. Ensure that all sections are filled out accurately to avoid delays.
If you encounter any questions or uncertainties while completing the Acord 130 form, don't hesitate to reach out to your insurance agent. They can provide guidance and clarify any points, ensuring that your application is accurate and complete.
Incomplete Contact Information: Many applicants forget to provide complete contact details, such as office and mobile phone numbers. This omission can delay communication and processing.
Incorrect Classification Codes: Using the wrong SIC or NAICS codes is a common mistake. These codes determine the insurance rates, so accuracy is crucial.
Failure to Include All Employees: Some applicants mistakenly exclude certain employees, especially part-time or seasonal workers. All employees must be accounted for to ensure proper coverage.
Neglecting to Disclose Prior Claims: Not providing a complete loss history can lead to issues. Insurers need this information to assess risk accurately.
Missing Signatures: An overlooked signature from the applicant or producer can render the application invalid. Always double-check that all required signatures are included before submission.
When submitting the ACORD 130 form for workers' compensation insurance, several other documents often accompany it. These documents help provide a comprehensive view of the applicant's business operations and insurance needs. Below is a list of commonly used forms and documents that complement the ACORD 130.
Including these documents with the ACORD 130 form can streamline the application process and ensure that all necessary information is provided. By preparing these forms in advance, applicants can help their agents or brokers facilitate a smoother experience in obtaining the right coverage for their business needs.
The ACORD 130 form is primarily used for applying for workers' compensation insurance. It is similar to the ACORD 125 form, which serves as a general insurance application. Both forms collect essential information about the applicant, including business details, contact information, and coverage needs. However, while the ACORD 130 is focused specifically on workers' compensation, the ACORD 125 covers a broader range of insurance types, making it more versatile for various insurance applications.
Another document that shares similarities with the ACORD 130 is the ACORD 133 form. This form is specifically used for assigned risk workers' compensation applications. Like the ACORD 130, it gathers information about the business and its operations. The primary distinction lies in the fact that the ACORD 133 is utilized when an applicant is unable to obtain workers' compensation insurance through the standard market, hence the need for the assigned risk pool.
The ACORD 101 form, known as the Additional Remarks Schedule, is also relevant. It is often attached to the ACORD 130 to provide additional space for comments or clarifications. Both forms emphasize the importance of thoroughness in the application process, ensuring that all necessary details are captured for accurate underwriting.
The ACORD 140 form, used for business auto insurance applications, shares a similar structure with the ACORD 130. Both documents require detailed information about the applicant's business operations, insurance needs, and prior coverage history. However, the ACORD 140 focuses specifically on auto-related risks, while the ACORD 130 is dedicated to workers' compensation.
Another related document is the ACORD 125 S form, which is a short form for commercial insurance applications. This document is streamlined for quicker submissions but still collects vital information similar to the ACORD 130. Both forms aim to facilitate the underwriting process, although the ACORD 125 S is designed for less complex situations.
The ACORD 150 form is used for property insurance applications and is similar in that it requests comprehensive details about the applicant's business and property exposures. Both forms prioritize clarity and completeness to assist underwriters in assessing risk, but the ACORD 150 is tailored to property coverage rather than workers' compensation.
Additionally, the ACORD 80 form, which pertains to general liability insurance applications, shares a common purpose with the ACORD 130. Both forms require information about the business's operations and risk exposures. The key difference lies in their focus; the ACORD 80 is concerned with liability risks, while the ACORD 130 addresses workers' compensation specifically.
The ACORD 200 form is another related document that deals with commercial insurance applications. Like the ACORD 130, it gathers extensive information about the applicant's business. However, the ACORD 200 encompasses a wider range of coverages, making it a more comprehensive option for businesses seeking various types of insurance.
Lastly, the ACORD 25 form, which is used for property and casualty insurance applications, is similar to the ACORD 130 in its structure and purpose. Both forms collect essential information to help insurers evaluate risk and determine coverage options. However, the ACORD 25 is broader in scope, addressing multiple types of insurance needs beyond just workers' compensation.
When filling out the ACORD 130 form, there are several important practices to keep in mind. Adhering to these guidelines can help ensure that your application is processed smoothly and efficiently.
By following these dos and don'ts, you can help facilitate a more efficient review process for your workers' compensation application.
This form is applicable to businesses of all sizes. Whether you run a small startup or a large corporation, the Acord 130 is designed to collect essential information for workers' compensation insurance.
Filling out the form does not automatically secure insurance. The form is a part of the application process, and coverage depends on the insurer's assessment of the information provided.
Any business that has employees and requires workers' compensation insurance must complete this form. This includes various sectors, from retail to construction.
Businesses may need to submit this form multiple times, especially during renewals or when there are significant changes in operations or staffing.
Information provided on this form is treated as confidential. Insurers are required to protect your data and use it solely for the purpose of underwriting and managing your policy.
Filling out the ACORD 130 form is a crucial step in applying for workers' compensation insurance. Here are some key takeaways to keep in mind: