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Get Acord 130 Form in PDF

The Acord 130 form is a standardized application used for obtaining workers' compensation insurance. This form collects essential information about the applicant's business operations, employee details, and coverage needs. Completing the Acord 130 accurately is crucial for ensuring proper insurance coverage and compliance with state regulations.

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The ACORD 130 form plays a crucial role in the realm of workers' compensation insurance applications, serving as a comprehensive tool that gathers essential information from businesses seeking coverage. Designed to facilitate the underwriting process, this form collects a variety of details, including the applicant's business structure, contact information, and the nature of operations. It requires applicants to disclose their years in business, classification codes, and estimated payroll figures, which are vital for determining premium rates. Additionally, the form addresses critical aspects such as loss history, prior coverage, and any specific business activities that may affect risk assessment, such as subcontracting or hazardous material handling. Each section of the ACORD 130 form is meticulously structured to ensure that underwriters receive a clear picture of the applicant's operations and risk profile, ultimately aiding in the accurate calculation of insurance premiums and coverage options. This document is not merely a formality; it is a foundational element in establishing a fair and effective workers' compensation policy tailored to the unique needs of the business.

Dos and Don'ts

When filling out the ACORD 130 form, it's essential to follow specific guidelines to ensure accuracy and compliance. Here are nine important dos and don'ts to consider:

Do provide accurate dates in the specified format (MM/DD/YYYY).
Do include all relevant contact information, such as office and mobile phone numbers.
Do specify the type of business entity clearly, whether it is a corporation, LLC, or sole proprietorship.
Do ensure that all employees included or excluded are listed with their correct remuneration or payroll details.
Do attach any necessary additional documentation, such as ACORD 101 for further remarks or explanations.

Don't leave any sections blank; incomplete forms may delay processing.
Don't provide misleading or inaccurate information, as this can lead to penalties.
Don't forget to include the proposed effective and expiration dates for the policy.
Don't overlook the need for signatures from authorized representatives of the applicant.

Document Attributes

Fact Name	Description
Purpose	The ACORD 130 form is used for applying for workers' compensation insurance.
Application Date	The form requires the date of application to be filled in MM/DD/YYYY format.
Agency Information	It collects details about the agency, including name, address, and contact information.
Business Structure	Applicants must indicate their business structure, such as corporation, LLC, or sole proprietor.
State-Specific Laws	For certain states, the form must comply with specific laws, such as Missouri's Section 287.090 RSMo.
Coverage Details	The form outlines various coverage options, including workers' compensation and employer's liability.
Prior Carrier Information	It requires a history of prior insurance carriers and any claims made in the past five years.
Signature Requirement	The application must be signed by an authorized representative of the applicant, confirming the accuracy of the information.

Key takeaways

When filling out the ACORD 130 form for workers' compensation insurance, it's essential to pay attention to several key aspects to ensure accuracy and compliance. Here are some important takeaways:

Accurate Information: Double-check all entries for accuracy. Incorrect information can lead to delays or issues with coverage.
Contact Details: Provide complete contact information for the applicant, including office and mobile phone numbers, and email addresses.
Business Structure: Clearly indicate the business structure (e.g., corporation, LLC, partnership) as it affects liability and coverage.
Years in Business: Specify the number of years the business has been operational. This can influence premium calculations.
Payroll Estimates: Provide accurate payroll estimates for all employees, including those who may be included or excluded from coverage.
Loss History: Include loss history for the past five years. This information is critical for underwriters to assess risk.
Employee Information: List all employees, noting any that should be excluded from coverage, and provide their duties and remuneration.
State Requirements: Be aware of specific state requirements and regulations that may apply to your business and its operations.
Signature Requirement: Ensure that the application is signed by an authorized representative of the applicant, such as an officer or partner.
Fraud Warning: Understand the implications of providing false information. Fraudulent applications can lead to severe penalties.

By following these guidelines, applicants can navigate the ACORD 130 form more effectively, ensuring they secure the appropriate coverage for their business needs.

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Example - Acord 130 Form

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

Detailed Instructions for Writing Acord 130

Completing the ACORD 130 form is a straightforward process that requires accurate information about your business and its operations. Follow these steps carefully to ensure that all necessary details are included, which will help facilitate your application for workers' compensation coverage.

Enter the application date in the format MM/DD/YYYY.
Fill in the agency name and address.
Provide the company and underwriter names.
Input the applicant's name and contact information, including office phone and mobile phone.
Complete the mailing address section, ensuring to include the ZIP + 4 or Canadian Postal Code.
Indicate the number of years in business and the relevant SIC and NAICS codes.
Provide the producer name and contact details for the CS representative.
Mark the appropriate business structure (e.g., sole proprietor, corporation, LLC).
Fill in the credit ID number and any applicable federal employer ID number.
Specify the status of submission and select the desired billing plan.
List the locations and their corresponding details, including the highest street address and ZIP code.
Provide policy information, including proposed effective and expiration dates.
Complete the sections for workers compensation, employer's liability, and any other coverages as needed.
Estimate the annual premium and fill in the necessary details for additional company information.
List the individuals included or excluded from coverage, providing their details and relationship to the business.
Fill in the prior carrier information and loss history for the past five years.
Provide a detailed description of operations and answer any general information questions.
Sign and date the application, ensuring it is completed by an authorized representative.

After completing the form, review all entries for accuracy. This diligence will help ensure a smooth submission process. Once verified, submit the form to your insurance agent or broker for further processing.

Documents used along the form

The Acord 130 form is a key document used in the workers' compensation insurance process. Along with this form, several other documents are often required to ensure a complete application. Here’s a list of common forms and documents that may accompany the Acord 130:

ACORD 133: This form is used for assigned risk applications. It provides additional details about the applicant's business and is essential when the applicant is unable to obtain coverage through the standard market.
ACORD 101: This is the Additional Remarks Schedule. It allows applicants to provide extra information or explanations that may not fit within the confines of the Acord 130 form.
Loss Run Reports: These reports detail the applicant's claims history over the past few years. They help insurers assess risk based on previous claims and losses.
Release of Liability Form: This document is essential for activities involving higher risks, ensuring that participants understand and accept potential dangers, and a blank form is here.
Experience Modification Rate (EMR) Worksheet: This document shows the applicant's EMR, which is a factor used to calculate workers' compensation premiums based on past claims history.
State-Specific Forms: Depending on the state, additional forms may be required. These could include specific declarations or disclosures mandated by state law.
Business Description Document: This document provides a detailed description of the business operations, including the types of work performed, which helps insurers evaluate risk more accurately.

Having these documents ready when submitting the Acord 130 can streamline the application process. It ensures that insurers have all the necessary information to assess the application effectively. Always check with your insurance agent or broker for any specific requirements that may apply to your situation.