Fill in a Valid Acord 130 Template

The Acord 130 form is a crucial document used in the application process for workers' compensation insurance. It collects essential information about the applicant's business, including details on operations, employees, and coverage needs. Completing this form accurately helps ensure that businesses receive the appropriate coverage tailored to their unique risks and requirements.

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The Acord 130 form serves as a crucial document in the realm of workers' compensation insurance applications. It collects essential information about the applicant's business, including the agency's details, the applicant's name and contact information, and the nature of the business operations. Key sections of the form require the applicant to provide data regarding their business structure, such as whether they are a sole proprietor, corporation, or partnership. The form also prompts the applicant to disclose their years in business, the Standard Industrial Classification (SIC) code, and the North American Industry Classification System (NAICS) code, which help insurers assess the risk associated with the business. Additionally, the Acord 130 includes sections for billing and audit information, policy details, and coverage options. It requires a comprehensive overview of the applicant's loss history and prior carrier information, which is vital for determining the premium rates. Furthermore, the form addresses specific questions regarding the nature of the business, including any hazardous materials handled, subcontracting practices, and employee demographics. Overall, the Acord 130 is designed to streamline the application process while ensuring that all pertinent information is gathered for effective risk assessment and premium calculation.

Documents used along the form

The Acord 130 form is a crucial document used in the application process for workers' compensation insurance. Along with this form, several other documents may be required to ensure a comprehensive submission. Each of these documents serves a specific purpose and helps provide the necessary information for underwriting and policy issuance.

Acord 133: This form is used to provide details about assigned risk coverage. It is often required when the applicant does not qualify for standard coverage and seeks coverage through the assigned risk pool.
Acord 101: The Additional Remarks Schedule is utilized to provide extra information or clarifications that cannot be accommodated within the primary forms. It allows applicants to elaborate on specific details regarding their business operations or coverage needs.
Loss Run Reports: These reports summarize the applicant's claims history over a specified period, typically five years. Insurers use this information to assess risk and determine premium rates.
Florida Articles of Incorporation: To establish a corporation in Florida, it is essential to complete the Florida PDF Forms, which detail the corporation's name, purpose, and structure.
Experience Modification Factor (EMF) Worksheet: This document calculates the experience modification factor, which adjusts premiums based on an employer's claim history compared to industry standards. It reflects the safety record of the business.
Payroll Records: Detailed payroll records are necessary to determine the estimated annual remuneration for employees. This information is critical for accurate premium calculations.
Safety Program Documentation: If a business has a written safety program, providing this documentation can help demonstrate the company's commitment to workplace safety, potentially influencing underwriting decisions.
Insurance History Form: This form outlines the applicant's previous insurance coverage, including any cancellations or non-renewals. Insurers review this information to understand the applicant's insurance background and risk profile.

Submitting these forms and documents alongside the Acord 130 can facilitate a smoother application process for workers' compensation insurance. Each document plays a vital role in presenting a complete picture of the applicant's business and insurance needs.

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Acord 130 Example

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

FAQ

What is the purpose of the ACORD 130 form?

The ACORD 130 form is used to apply for workers' compensation insurance. It collects essential information about the applicant's business operations, employee details, and coverage needs. This information helps insurance providers assess risk and determine appropriate premiums.
What information is required on the ACORD 130 form?

The form requires various details, including:
- Applicant's name and contact information
- Business structure (e.g., corporation, LLC, partnership)
- Years in business and relevant industry codes (SIC and NAICS)
- Details about employees, including their roles and remuneration
- Prior insurance coverage and loss history
Completing the form accurately is crucial for obtaining the correct coverage and premium rates.
How does the ACORD 130 form affect my insurance premium?

The information provided on the ACORD 130 form directly influences the calculation of your insurance premium. Insurers evaluate factors such as the number of employees, industry classification, and prior claims history to determine risk. Higher risk factors may result in increased premiums, while lower risk factors can lead to discounts.
What should I do if I have a loss history?

If you have a loss history, it is essential to disclose this information on the ACORD 130 form. Provide details about any claims made in the past five years, including the nature of the claims and amounts paid. Transparency is vital, as failure to disclose this information can lead to issues with coverage or claims in the future.
Can I make changes to the ACORD 130 form after submission?

Yes, you can make changes to the ACORD 130 form after submission, but it may require additional documentation. If your business circumstances change or if you discover inaccuracies in the submitted information, contact your insurance agent or broker promptly. They can guide you on how to amend the application and ensure your coverage reflects your current situation.

Key takeaways

Filling out the ACORD 130 form is a critical step in obtaining workers' compensation insurance. Here are some key takeaways to ensure you complete it accurately and effectively:

Provide Accurate Information: Ensure that all fields are filled out with correct and current information. This includes details about your business, such as the name, address, and type of entity.
Understand Coverage Needs: Clearly specify the types of coverage you require. This includes workers' compensation, employer's liability, and any additional coverages that may be necessary for your operations.
Document Employee Information: Include detailed information about employees, including their roles, salaries, and whether they should be included or excluded from coverage.
Review Loss History: Provide information on any claims made in the past five years. This helps insurers assess risk and determine premiums.
Be Aware of State Requirements: Different states may have specific requirements or forms that need to be attached. Check your state's regulations to ensure compliance.
Signature Requirement: The form must be signed by an authorized representative of the applicant. This confirms that the information provided is accurate and complete.
Keep a Copy: After submitting the form, retain a copy for your records. This can be helpful for future reference or in case of any disputes.

Completing the ACORD 130 form carefully can help streamline the insurance process and ensure that your business is adequately protected. Always consult with an insurance professional if you have questions about specific sections or requirements.

Form Characteristics

Fact Name	Description
Purpose	The ACORD 130 form is used for applying for workers' compensation insurance in the United States.
Application Date	Applicants must provide the date of application in MM/DD/YYYY format.
Business Information	It collects essential details about the applicant's business, including years in operation and type of business structure.
Contact Details	The form requires contact information for the applicant and the agency, including phone numbers and email addresses.
Coverage Information	Applicants must specify the type of workers' compensation coverage and any additional endorsements needed.
State-Specific Requirements	Some states have specific regulations that must be adhered to, such as Missouri's Section 287.090 RSMo for exclusions.
Loss History	The form requests information on the applicant's loss history for the past five years, including claims and reserves.
Fraud Warning	It includes a warning about the consequences of providing false information, which can lead to criminal charges.
Signature Requirement	The application must be signed by an authorized representative, such as an officer or owner, to validate the information provided.
Privacy Notice	A privacy notice is included, informing applicants about the collection and use of their personal information.

Fill in a Valid Acord 130 Template

Documents used along the form

Other PDF Templates

Acord 130 Example

FAQ

What is the purpose of the ACORD 130 form?

What information is required on the ACORD 130 form?

How does the ACORD 130 form affect my insurance premium?

What should I do if I have a loss history?

Can I make changes to the ACORD 130 form after submission?

Key takeaways

Form Characteristics