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Fill in a Valid Acord 130 Form

The ACORD 130 form is a crucial document used in the application process for workers' compensation insurance. It collects essential information about a business, including its operations, employee details, and coverage needs. Properly completing this form ensures that applicants receive accurate insurance quotes tailored to their specific circumstances.

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Document Sample

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

Document Information

Fact Name	Description
Purpose	The ACORD 130 form is used to apply for workers' compensation insurance, providing necessary information about the applicant and their business operations.
Governing Law	This form is governed by state-specific laws regarding workers' compensation, which can vary significantly by state. For example, Missouri's regulations include specific requirements under Section 287.090 RSMo.
Information Required	Applicants must provide detailed information, including business type, employee classifications, and prior loss history, to facilitate accurate underwriting.
Submission Status	The form includes a section to indicate the status of submission, such as whether the application is bound, quoted, or under audit.

Acord 130 - Usage Guidelines

Filling out the ACORD 130 form is an essential step in obtaining workers' compensation insurance. This form collects important information about your business and its operations. Follow the steps below to ensure you complete the form accurately.

Enter the Date: Fill in the date of the application in MM/DD/YYYY format.
Agency Information: Write the agency name and address where applicable.
Company Details: Provide the name of the insurance company and underwriter.
Applicant Information: Fill in your name, office phone, mobile phone, and mailing address, including ZIP + 4 or Canadian Postal Code.
Business Information: Indicate the number of years in business and the Standard Industrial Classification (SIC) code.
Producer Information: Include the producer's name, North American Industry Classification System (NAICS) code, and contact details.
Business Structure: Mark the appropriate box to indicate whether you are a sole proprietor, corporation, LLC, trust, unincorporated association, partnership, joint venture, or other entity.
Contact Information: Fill in the contact details for inspection, accounting records, and claims information.
Employee Information: List individuals included or excluded, including their names, dates of birth, titles, duties, class codes, and remuneration/payroll.
Policy Information: Provide details on the proposed effective and expiration dates, and indicate any additional coverages or endorsements.
Prior Carrier Information: Fill out the loss history for the past five years, including carrier names, policy numbers, annual premiums, and claims information.
General Information: Answer all yes/no questions honestly and provide explanations where necessary.
Signature: The applicant must sign and date the form, confirming that the information provided is accurate.

After completing the form, review all entries for accuracy. Attach any necessary documents, such as loss runs or additional remarks, before submitting it to the appropriate agency or insurance provider.

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Dos and Don'ts

When filling out the ACORD 130 form, it is essential to follow certain guidelines to ensure accuracy and compliance. Here are four things to do and avoid:

Do: Provide accurate contact information for all parties involved, including the applicant and the agency.
Do: Clearly indicate the type of business structure (e.g., corporation, LLC) to avoid confusion.
Do: Include all relevant employee details, including their roles and remuneration, to ensure correct premium calculations.
Do: Attach any necessary supporting documents, such as loss runs or additional remarks, to provide context.

Don't: Leave any sections blank; incomplete information may delay processing or result in errors.
Don't: Provide misleading or inaccurate information, as this can lead to penalties or denial of coverage.
Don't: Forget to sign the application; an unsigned form may be considered invalid.
Don't: Ignore the specific requirements for your state, as regulations can vary significantly.

Common mistakes

Failing to provide accurate contact information. Ensure that all phone numbers and email addresses are correct. Inaccurate contact details can delay communication and processing.
Not including the correct Federal Employer ID Number. This number is crucial for identifying your business and ensuring compliance with tax regulations.
Omitting employee information. Clearly list all employees included or excluded from coverage. This includes their roles, salaries, and relationships to the business.
Using outdated or incorrect business classification codes. Make sure to use the current SIC and NAICS codes that accurately reflect your business operations.
Neglecting to detail prior loss history. Providing a complete loss history helps insurers assess risk accurately. Include all relevant claims and their details.
Failing to sign the application. The application must be signed by an authorized representative of the business. An unsigned application is considered incomplete.
Not reviewing the entire application for accuracy. Double-check all entries for errors or omissions before submission to avoid delays or issues with coverage.

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