The Acord 130 form is a crucial document used for applying for workers' compensation insurance. It collects essential information about the business, including its operations, employee details, and coverage needs. Completing this form accurately is vital for securing the appropriate coverage for your workforce.
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The Acord 130 form serves as a vital tool in the realm of workers' compensation insurance applications. Designed to gather essential information, it facilitates the underwriting process for businesses seeking coverage. This comprehensive form requires details such as the applicant's name, business structure, and years in operation. It also captures critical contact information, including phone numbers and email addresses, which help insurers maintain communication throughout the application process. The Acord 130 delves into specifics regarding the nature of the business, including the type of operations, estimated annual payroll, and the classification of employees. Additionally, it addresses prior insurance coverage and loss history, ensuring that underwriters have a clear understanding of the applicant's risk profile. The form includes sections for proposed policy information, billing plans, and additional coverages, enabling businesses to tailor their insurance needs effectively. By completing the Acord 130, applicants not only demonstrate their commitment to providing accurate information but also pave the way for securing appropriate workers' compensation coverage tailored to their unique operational requirements.
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
Contract Proposal for Construction - Used to formally request construction services from a contractor.
A California Non-disclosure Agreement (NDA) is a legal document designed to protect confidential information shared between parties. This form establishes clear guidelines on what information must remain private and outlines the obligations of each party. To ensure your sensitive information is safeguarded, consider filling out the NDA form by clicking the button below or visit California PDF Forms for additional resources.
1750 Form - Prepared by authorized personnel, the form underscores accountability.
Understanding the Acord 130 form can be challenging, and several misconceptions often arise. Here are seven common misconceptions explained:
This form is used by businesses of all sizes to apply for workers' compensation insurance. Small businesses also need to fill it out to ensure they have the necessary coverage.
While the Acord 130 form is a step in the application process, it does not guarantee that coverage will be issued. Underwriters will review the information provided before making a decision.
Many sections of the Acord 130 form are mandatory. Providing complete and accurate information is crucial for proper evaluation and to avoid delays in processing.
The form must be signed by an authorized representative of the applicant, which can include an officer, owner, or partner. This ensures accountability for the information provided.
Applicants must provide loss history for the past five years. This information helps insurers assess risk and determine premiums accurately.
The Acord 130 form may have variations based on state requirements. It’s important to check for any specific regulations or additional information needed in your state.
While the information on the Acord 130 form should be accurate at the time of submission, changes can be made if necessary. It’s important to communicate any updates to the insurer promptly.
The ACORD 130 form is a critical document used in the application for workers' compensation insurance. To effectively complete this process, several other forms and documents are often required. Below is a list of four commonly used documents that complement the ACORD 130 form.
Understanding these additional documents is essential for a smooth application process. Each one plays a vital role in ensuring that the applicant receives appropriate coverage tailored to their business needs.