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Free Acord 130 Template

The Acord 130 form is a crucial application used for obtaining workers' compensation insurance. This form collects essential information about your business, including details on operations, employee classifications, and coverage needs. Filling it out accurately is vital to ensure your business is properly protected.

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Table of Contents

The ACORD 130 form plays a crucial role in the workers' compensation insurance landscape, serving as a standardized application that streamlines the process for businesses seeking coverage. This form captures essential information about the applicant, including their business structure, years in operation, and nature of their work. It requires details such as the agency's name, contact information, and the proposed effective and expiration dates for the policy. Additionally, the form asks for a comprehensive breakdown of employees, including their roles and remuneration, which is vital for calculating premiums. Businesses must also disclose any past claims history and provide insight into their operational practices, ensuring that insurers have a complete picture of the risks involved. By addressing aspects like additional coverages, endorsements, and billing plans, the ACORD 130 form facilitates a smoother interaction between businesses and insurance providers, making it an indispensable tool in securing workers' compensation coverage. Understanding its components and filling it out accurately can significantly impact a company's insurance experience.

Document Specifics

Fact Name	Description
Purpose	The ACORD 130 form is used to apply for workers' compensation insurance coverage. It collects essential information about the applicant's business and operations.
Governing Law	The form is subject to state-specific regulations. For example, in Missouri, exclusions must meet the requirements of Section 287.090 RSMo.
Submission Requirements	Applicants must provide detailed information about their business operations, including employee classifications and prior insurance history.
Fraud Warning	Filing false information on the ACORD 130 can lead to serious penalties, including criminal charges. States like Florida classify this as a felony.

Similar forms

ACORD 133 - Workers Compensation Assigned Risk Plan Application: This document is used for businesses that are unable to obtain workers' compensation insurance in the standard market. Like the Acord 130, it collects detailed information about the business and its operations.
Non-disclosure Agreement (NDA): Protect your confidential information with a Non-disclosure Agreement in Arizona. This document clarifies what is private and ensures that each party understands their responsibility to maintain confidentiality. Learn more about the form at Arizona PDF Forms.
ACORD 125 - Commercial Insurance Application: This form serves as a general application for commercial insurance. It shares similarities with the Acord 130 in that both require comprehensive information about the applicant's business and its insurance needs.
ACORD 101 - Additional Remarks Schedule: This document allows applicants to provide additional information or remarks that may not fit in other forms. It complements the Acord 130 by offering space for further details on coverage needs or business operations.
ACORD 27 - Certificate of Liability Insurance: This certificate provides proof of insurance coverage. While it serves a different purpose, both forms require detailed information about the insured entity and its coverage.
ACORD 28 - Evidence of Property Insurance: Similar to the Acord 27, this document shows proof of property insurance. Both forms require specifics about the insured properties and coverage limits, making them comparable to the Acord 130 in terms of information gathering.
ACORD 140 - Commercial General Liability Application: This application is used to apply for general liability insurance. Like the Acord 130, it requests detailed information about the business, including its operations and risk factors.
ACORD 130S - Workers Compensation Supplemental Application: This form is often used alongside the Acord 130 for additional information. It focuses on specific coverage details, much like the detailed sections found in the Acord 130.
ACORD 2 - General Application: This document serves as a broad application for various types of insurance. It requires similar information about the business and its operations, paralleling the Acord 130 in its comprehensive nature.
ACORD 25 - Certificate of Insurance: While primarily used to provide evidence of insurance, it also requires detailed information about the insured, similar to what is needed in the Acord 130.

Free Acord 130 File

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

Understanding Acord 130

What is the Acord 130 form used for?

The Acord 130 form is primarily used to apply for workers' compensation insurance. It collects essential information about the applicant's business, including details about operations, employee classifications, and estimated payroll. This information helps insurance providers assess risk and determine appropriate coverage and premium rates.

Who needs to fill out the Acord 130 form?

Any business seeking workers' compensation insurance must complete the Acord 130 form. This includes sole proprietors, corporations, partnerships, and other business entities. The form is necessary for both new applicants and those looking to renew or modify existing coverage.

What information is required on the Acord 130 form?

The form requires various details, such as the agency name, applicant name, contact information, business structure, and years in operation. Additionally, it asks for specifics about employee classifications, payroll estimates, and prior insurance coverage. Accurate and complete information is crucial for the underwriting process.

How does the Acord 130 form impact my workers' compensation premium?

The information provided on the Acord 130 form directly influences the calculation of the workers' compensation premium. Factors such as the nature of the business, employee classifications, and payroll estimates are considered. If the information is inaccurate or incomplete, it may lead to higher premiums or coverage issues.

What should I do if I have questions while filling out the Acord 130 form?

If questions arise while completing the Acord 130 form, it is advisable to consult with an insurance agent or broker. They can provide guidance on specific sections and help ensure that all necessary information is accurately reported. This can prevent delays in processing the application.

What happens after I submit the Acord 130 form?

Once submitted, the insurance company will review the information provided on the Acord 130 form. They may request additional documentation or clarification if needed. After the review process, the insurer will issue a quote for coverage, which will outline the terms, conditions, and premium costs associated with the policy.

Dos and Don'ts

When filling out the ACORD 130 form, it's essential to approach the process with care. Here’s a list of things to do and avoid to ensure your application is accurate and complete.

Do: Provide accurate contact information for all parties involved, including phone numbers and email addresses.
Do: Clearly state the nature of your business and include detailed descriptions of operations and products.
Do: Review the form thoroughly for any missing information before submission.
Do: Attach any necessary documents, such as loss runs or additional remarks, to support your application.
Do: Ensure that all employees included in the application are accurately listed with their roles and remuneration.

Don't: Leave any sections blank; incomplete information can delay processing.
Don't: Provide false or misleading information, as this can lead to serious legal consequences.
Don't: Forget to sign the application; an unsigned form is not valid.
Don't: Assume that all questions are optional; each question is important for assessing your coverage.
Don't: Submit the form without a final review; errors can lead to complications down the line.

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