The ACORD 130 form is a standardized application used to obtain workers' compensation insurance. This form collects essential information about the applicant's business operations, employee details, and insurance history. Completing the ACORD 130 accurately is crucial for securing appropriate coverage and ensuring compliance with state regulations. Fill out the form by clicking the button below.
The ACORD 130 form serves as a crucial document in the realm of workers' compensation insurance applications. It collects essential information from applicants, including their business structure, years in operation, and the nature of their business activities. The form requires details such as the applicant's name, contact information, and federal employer identification number. It also captures the insurance coverage sought, including workers' compensation, employer's liability, and any additional coverages or endorsements. Furthermore, the ACORD 130 form facilitates the assessment of risk by detailing employee classifications, payroll estimates, and loss history over the past five years. This comprehensive information allows insurance providers to evaluate the applicant's risk profile accurately and determine appropriate premium rates. By ensuring that all necessary data is presented clearly, the ACORD 130 form streamlines the application process for both applicants and insurers.
The ACORD 130 form is a critical document used in the workers' compensation insurance application process. However, several other forms and documents often accompany it to provide a comprehensive view of the applicant's business and coverage needs. Here’s a brief overview of some of these important documents.
Each of these documents plays a vital role in the workers' compensation application process. Together, they provide a complete picture of the applicant's business, ensuring that the insurance provider can offer the most appropriate coverage and pricing. Understanding these forms can help applicants navigate the complexities of securing workers' compensation insurance more effectively.
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
Filling out the ACORD 130 form is an essential step in applying for workers' compensation insurance. This form collects various details about your business, its operations, and its insurance needs. Accurate completion is crucial for ensuring that you receive the appropriate coverage and terms.
The ACORD 125 form is commonly used in the insurance industry, similar to the ACORD 130 form. It serves as a general insurance application that collects essential information about the applicant, including business details, coverage requirements, and underwriting information. Both forms aim to streamline the application process and ensure that insurers have the necessary data to assess risk and provide quotes. The ACORD 125 focuses on various types of insurance beyond just workers' compensation, making it a versatile tool for different insurance needs.
Another document that shares similarities with the ACORD 130 is the ACORD 133 form. This form is specifically designed for assigned risk applications in workers' compensation insurance. Like the ACORD 130, it gathers information about the business and its operations. The key difference lies in its focus on businesses that may not qualify for standard coverage due to higher risk factors. Both forms require detailed information about the business structure and employee classifications to facilitate accurate underwriting.
In the realm of vehicle transactions, understanding the importance of the Florida Motor Vehicle Bill of Sale is crucial, as it provides a definitive record of ownership transfer and ensures all legal requirements are met. For more information about this essential document, you can visit https://fastpdftemplates.com/, where you can find helpful templates and resources to aid in the process.
The ACORD 140 form is also relevant, as it is used for commercial auto insurance applications. Similar to the ACORD 130, it collects information about the applicant's business, including the type of operations and vehicle usage. Both forms are essential for determining appropriate coverage and premiums. The ACORD 140 is specifically tailored for vehicles, while the ACORD 130 is focused on workers' compensation, highlighting the different aspects of business insurance.
The ACORD 151 form is utilized for property insurance applications and has similarities with the ACORD 130 in terms of the information it collects. Both forms require details about the business operations and any potential risks associated with the property or employees. The ACORD 151 focuses on property coverage, while the ACORD 130 emphasizes workers' compensation, but both serve the purpose of providing insurers with comprehensive information for risk assessment.
In addition, the ACORD 160 form, used for general liability insurance applications, shares commonalities with the ACORD 130. Both forms gather critical information about the applicant's business activities, employee classifications, and coverage needs. The ACORD 160 focuses on liability risks associated with business operations, whereas the ACORD 130 is specifically tailored for workers' compensation, emphasizing the different types of insurance coverage businesses may require.
The ACORD 25 form is another document that is similar to the ACORD 130, as it is used for commercial property insurance applications. Both forms collect essential details about the business, including its operations, employee classifications, and coverage requirements. While the ACORD 130 focuses on workers' compensation, the ACORD 25 is designed to assess property risks, making them complementary in the insurance application process.
The ACORD 101 form, known as the Additional Remarks Schedule, is often used in conjunction with the ACORD 130. It allows applicants to provide additional information or clarifications that may not fit within the confines of the primary application. This flexibility is essential for both forms, as it ensures that all relevant details are captured for underwriting purposes.
The ACORD 126 form is used for personal insurance applications and bears similarities to the ACORD 130 in its approach to gathering applicant information. Both forms focus on the specifics of the applicant's situation, whether it be for business or personal coverage. The ACORD 126 is tailored for individual insurance needs, while the ACORD 130 addresses the requirements of businesses seeking workers' compensation insurance.
The ACORD 3 form, which serves as a certificate of insurance, is another document that relates to the ACORD 130. While it is not an application form, it provides proof of coverage and can be used in conjunction with the ACORD 130 to demonstrate that a business has the necessary workers' compensation insurance in place. Both documents are essential for ensuring compliance and protecting businesses from potential liabilities.
Lastly, the ACORD 130 form is similar to the ACORD 140S form, which is a simplified version of the ACORD 140 for smaller businesses. Both forms aim to collect relevant information about the business and its insurance needs. The ACORD 140S is tailored for businesses with fewer complexities, while the ACORD 130 is designed for comprehensive workers' compensation applications, highlighting the varying levels of detail required based on business size and risk.
Form 1040 Schedule C - Complex business structures may require additional forms or schedules beyond Schedule C.
For those interested in simplifying their estate planning, the Arizona Transfer-on-Death Deed form serves as an effective tool that facilitates the transfer of real estate directly to beneficiaries, eliminating the need for probate. This legal document ensures that property is passed on according to the owner's wishes, preventing potential conflicts and delays. To learn more about this useful form, you can visit https://arizonapdfforms.com/transfer-on-death-deed.
Employee Change Form - Utilize this form to reflect changes in employee benefits eligibility.
Here are seven common misconceptions about the ACORD 130 form: