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Printable Acord 130 Form in PDF

The Acord 130 form serves as a comprehensive application for workers' compensation insurance. It collects essential information about the applicant's business, including their operations, employee details, and coverage needs. Understanding this form is crucial for both applicants and insurance providers to ensure proper coverage and compliance.

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WORKERS COMPENSATION APPLICATION	DATE (MM/DD/YYYY)
WORKERS COMPENSATION APPLICATION

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

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
STATE	LOC #	NAME	DATE OF BIRTH	RELATIONSHIP	SHIP %	DUTIES	INC/EXC	CLASS CODE	REMUNERATION/PAYROLL

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 #

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		$	PREMIUM DISCOUNT		$
		$	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

Documents used along the form

The ACORD 130 form serves as a crucial document in the process of applying for workers' compensation insurance. However, several other forms and documents often accompany it to provide a comprehensive view of the applicant's business operations, risk factors, and coverage needs. Below are five commonly used forms that complement the ACORD 130.

ACORD 133 - Workers Compensation Assigned Risk Plan Application: This form is utilized when an applicant is unable to obtain workers' compensation coverage through standard markets. It captures essential information for the assigned risk pool and helps insurers assess the risk associated with the business.
ACORD 101 - Additional Remarks Schedule: This document allows applicants to provide further details or clarifications that may not fit within the confines of the ACORD 130. It is particularly useful for explaining unique business operations or addressing specific underwriting questions.
Loss Run Reports: These reports detail the claims history of a business over a specified period, typically the last five years. Insurers review loss runs to evaluate the frequency and severity of past claims, which can significantly impact the underwriting decision and premium rates.
State Rating Worksheet: This form collects detailed information about the business's operations, employee classifications, and payroll estimates. It assists in calculating the appropriate premium based on the specific risks associated with the business and its workforce.
California Motor Vehicle Bill of Sale: This form is crucial for the legal transfer of vehicle ownership in California. For detailed guidance on how to fill out this form, refer to legalpdfdocs.com.
Employer's Liability Insurance Application: While the ACORD 130 primarily focuses on workers' compensation, this application addresses the need for employer's liability coverage. It provides additional protection against claims from employees for work-related injuries that may not be covered under workers' compensation laws.

In conclusion, these accompanying forms and documents enhance the information provided in the ACORD 130, facilitating a more accurate assessment of the applicant's insurance needs. Together, they create a comprehensive profile that aids insurers in making informed decisions regarding coverage and premiums.

Similar forms

ACORD 130: This form is specifically designed for workers' compensation insurance applications. It gathers essential information about the applicant's business, including details about employees and coverage needs.
Durable Power of Attorney: This legal document allows individuals to appoint someone they trust to manage their financial and legal matters, even in cases of incapacity, similar to the authority granted in a Durable Power of Attorney.
ACORD 125: Similar to the ACORD 130, the ACORD 125 is a general application for property and casualty insurance. It collects information about the applicant's business operations and insurance needs, but it focuses on broader coverage areas beyond just workers' compensation.
ACORD 133: This form is used for assigned risk applications in workers' compensation insurance. Like the ACORD 130, it requires detailed business information, but it specifically addresses the needs of businesses that may not qualify for standard coverage.
ACORD 101: The Additional Remarks Schedule complements various ACORD forms, including the ACORD 130. It allows applicants to provide additional information or clarifications that may not fit within the standard application format.
ACORD 140: This is the General Liability Application, which, like the ACORD 130, collects information about the applicant’s business. However, it focuses on liability coverage rather than workers' compensation, making it relevant for businesses looking for comprehensive insurance solutions.

Misconceptions

Misconception 1: The Acord 130 form is only for large businesses.

This form is designed for all types of businesses, regardless of size. Small businesses also need to provide information about their workers' compensation coverage, making the Acord 130 relevant to everyone.

Misconception 2: Completing the Acord 130 form is optional.

In many cases, submitting this form is a requirement for obtaining workers' compensation insurance. It provides essential information that insurers need to assess risk and determine premiums.

Misconception 3: The Acord 130 form is only about payroll information.

While payroll is a significant part of the form, it also includes details about the business operations, employee classifications, and any prior claims history. All of this information helps insurers evaluate the overall risk.

Misconception 4: The form is the same across all states.

Different states may have specific requirements or additional forms to accompany the Acord 130. It's important to check local regulations to ensure compliance.

Misconception 5: Only the business owner needs to sign the form.

While the owner or an authorized representative must sign, it's often necessary for the producer or agent to sign as well. This ensures that all parties involved are aware of the information submitted.

Misconception 6: The Acord 130 form guarantees coverage.

Submitting the form does not guarantee that coverage will be issued. Insurers will still review the information and may ask for additional details before making a decision.

Misconception 7: The information provided on the form is confidential and cannot be shared.

While the form contains sensitive information, insurers may share it with relevant parties, such as state regulators or other insurers, to assess risk and ensure compliance with regulations.

Understanding Acord 130

What is the purpose of the ACORD 130 form?
The ACORD 130 form is primarily used to apply for workers' compensation insurance. This form collects essential information about the business, including its structure, the number of employees, estimated payroll, and previous insurance coverage. By providing this information, businesses can obtain accurate quotes and coverage options tailored to their specific needs.
What information do I need to provide on the ACORD 130 form?
When completing the ACORD 130 form, you will need to supply various details. This includes the name and address of your agency, the applicant's name, contact information, and the type of business entity (such as sole proprietor or corporation). Additionally, you will need to provide information about your business operations, the number of employees, and estimated payroll. It is also crucial to disclose any prior insurance coverage and loss history for the past five years.
How does the ACORD 130 form affect my insurance premium?
The information you provide on the ACORD 130 form directly influences your insurance premium. Insurers assess factors such as the number of employees, estimated payroll, and any claims history to determine the risk associated with your business. A higher risk may lead to a higher premium, while a lower risk could result in more favorable rates. Therefore, accuracy in completing the form is vital to ensure you receive an appropriate premium quote.
What should I do if I have questions while filling out the form?
If you encounter questions or uncertainties while completing the ACORD 130 form, it is advisable to consult with your insurance agent or broker. They can provide guidance and clarification on specific sections of the form. Additionally, they can help ensure that all necessary information is included, which can prevent delays in processing your application.
What happens after I submit the ACORD 130 form?
After submitting the ACORD 130 form, the insurance company will review the information provided. They may contact you for additional details or clarification if needed. Once the review is complete, you will receive a quote for your workers' compensation insurance. If you agree to the terms, you can proceed with securing the policy. It is essential to keep a copy of the submitted form for your records.