The Acord 130 form is a standard application used in the United States for obtaining workers' compensation insurance. This form collects essential information about a business, including its operations, employee details, and coverage needs. Completing the Acord 130 accurately is crucial for securing the right insurance coverage and ensuring compliance with state regulations.
The ACORD 130 form serves as a vital tool in the realm of workers' compensation insurance applications. This comprehensive document collects essential information from businesses seeking coverage, including details about the applicant, their business operations, and the desired insurance terms. Key sections of the form require the applicant to provide their agency name, contact information, and business structure, such as whether they operate as a corporation, LLC, or sole proprietorship. Additionally, it gathers data on estimated payroll, employee classifications, and prior loss history, which are critical for determining premium rates. The form also addresses various coverage options, including employer's liability and specific deductibles, allowing insurers to tailor policies to the unique needs of each business. Furthermore, applicants must disclose any prior insurance coverage and any relevant business operations that could impact risk assessment. Completing the ACORD 130 accurately ensures that businesses receive appropriate coverage while facilitating a smoother underwriting process.
What is the purpose of the ACORD 130 form?
The ACORD 130 form is a Workers Compensation Application used by businesses to apply for workers' compensation insurance. This form collects essential information about the business, including its structure, operations, and employee details. Insurers use this information to assess the risk associated with providing coverage and to determine the appropriate premium. By accurately filling out the form, businesses can ensure they receive a fair quote and adequate coverage for their employees.
What information is required on the ACORD 130 form?
The ACORD 130 form requires various details about the business and its operations. Key sections include the agency name and address, applicant information, and the nature of the business. Businesses must provide their years in operation, the type of business entity (such as corporation or LLC), and the number of employees. Additionally, information about previous workers' compensation coverage and loss history is crucial. The form also asks for specific details about employee roles, remuneration, and any exclusions that may apply. Completing this information accurately helps insurers evaluate the application effectively.
How does the ACORD 130 form impact my workers' compensation premium?
The information provided on the ACORD 130 form significantly influences the calculation of your workers' compensation premium. Insurers analyze details such as the type of business, employee classifications, and historical loss data to assess risk. For instance, a business with a high number of claims may face higher premiums. Conversely, businesses that demonstrate a commitment to safety and have fewer claims may qualify for discounts. Therefore, ensuring that the form is filled out accurately and comprehensively is essential for obtaining a fair premium rate.
What should I do if I have questions while filling out the ACORD 130 form?
If you encounter questions or uncertainties while completing the ACORD 130 form, it is advisable to consult with your insurance agent or broker. They can provide guidance and clarification on specific sections of the form. Additionally, many insurance companies offer resources or customer support to assist applicants. Taking the time to seek help can prevent mistakes and ensure that your application is complete and accurate, ultimately leading to better coverage options.
Filling out the ACORD 130 form is an essential step in applying for workers' compensation insurance. Here are some key takeaways to consider:
Understanding the Acord 130 form can be challenging, and several misconceptions often arise. Here are seven common misunderstandings, along with clarifications to help you navigate this important document.
Many believe that only large corporations need to fill out this form. In reality, any business that has employees and requires workers' compensation insurance must complete the Acord 130, regardless of size.
Some think that the Acord 130 is exclusively for new businesses seeking insurance. However, it is also used for renewals and changes to existing policies.
While the Acord 130 is standardized, specific state regulations can vary. It's essential to check your state's requirements to ensure compliance.
Some applicants believe they can omit their claims history. In fact, providing accurate loss history for the past five years is crucial for obtaining an accurate premium rate.
Filling out the Acord 130 does not automatically secure coverage. The insurance company will review the application and determine eligibility based on various factors.
Leaving sections blank can lead to delays or denials. It's best to provide as much information as possible, even if it means indicating that a section does not apply.
Many think they only need to submit the Acord 130 once. In reality, updates, renewals, and changes in business operations may require resubmission of the form.
By addressing these misconceptions, you can approach the Acord 130 form with greater confidence and ensure that your business meets its workers' compensation insurance needs 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
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Incomplete Contact Information: Failing to provide complete contact details can lead to delays. Ensure that the applicant's name, office phone, and email address are filled out correctly. Missing or incorrect information can hinder communication and processing.
Incorrect Business Classification Codes: Using the wrong SIC or NAICS codes can affect the premium rates. These codes help insurers understand the nature of the business. Double-check that the classifications accurately reflect the operations of the business.
Omitting Employee Information: Not including all employees in the rating section is a common oversight. Every employee, including part-time and seasonal workers, must be accounted for. This ensures that the payroll and premiums are calculated correctly.
Failure to Disclose Prior Claims: Neglecting to provide a complete loss history can result in complications. Insurers need to assess risk accurately, and undisclosed claims may lead to policy cancellation or denial of coverage.
Ignoring Additional Coverages: Not specifying additional coverages or endorsements can leave gaps in protection. If your business requires specific coverage, it’s essential to mention these needs in the application to avoid unexpected risks.
When filling out the ACORD 130 form, it's essential to be thorough and accurate. Here are seven tips to help you navigate the process effectively:
The ACORD 125 form is a commercial insurance application that serves a similar purpose to the ACORD 130 form. Both forms are designed to gather essential information about a business to facilitate the underwriting process. The ACORD 125 focuses on general liability and property insurance, while the ACORD 130 specifically addresses workers' compensation. However, both documents require details about the applicant's business operations, including the nature of the business, estimated payroll, and prior insurance history. This commonality ensures that insurers have a comprehensive understanding of the risks associated with the applicant's business.
The ACORD 133 form, known as the Workers Compensation Supplement, complements the ACORD 130 form by providing additional details specifically related to workers' compensation coverage. While the ACORD 130 collects baseline information necessary for the application, the ACORD 133 focuses on specific aspects such as assigned risk status and coverage details. This supplementary document allows insurers to evaluate the applicant's risk profile more accurately, ensuring that all relevant factors are considered in the underwriting process.
The ACORD 140 form is another document that shares similarities with the ACORD 130. This form is used for general liability insurance applications and captures details about the applicant's business operations, including descriptions of services provided and any subcontracting arrangements. Like the ACORD 130, the ACORD 140 requires information about the applicant's loss history and prior insurance coverage. This helps insurers assess potential risks and determine appropriate coverage options for the business.
The ACORD 151 form, which is a business auto application, also parallels the ACORD 130 in that both forms collect vital information about the applicant's operations. The ACORD 151 focuses on vehicle usage, driver information, and vehicle types, while the ACORD 130 emphasizes employee-related risks and workers' compensation. Despite their different focuses, both forms require detailed disclosures about the applicant's activities to enable insurers to make informed underwriting decisions.
The ACORD 154 form is utilized for commercial property applications and shares a similar structure with the ACORD 130. Both forms require information about the applicant's business, including property locations, values, and loss history. The ACORD 154 specifically addresses property risks, while the ACORD 130 focuses on employee-related risks. This alignment in structure and required information streamlines the application process for businesses seeking multiple types of insurance coverage.
The ACORD 160 form is a certificate of insurance that functions similarly to the ACORD 130 in terms of providing essential information about coverage. While the ACORD 130 serves as an application for workers' compensation insurance, the ACORD 160 acts as proof of coverage once a policy is issued. Both documents include details about the insured party, coverage limits, and effective dates, ensuring that all parties involved have a clear understanding of the insurance protections in place.
In addition to the various ACORD forms, those involved in trailer transactions should consider the importance of a formalized process, such as completing the New York Trailer Bill of Sale form. This legal document is essential for recording the sale and transfer of ownership. For more details, you can visit https://vehiclebillofsaleform.com/trailer-bill-of-sale-template/new-york-trailer-bill-of-sale-template/, which outlines the necessary information required for the sale and provides guidance on how to complete the form accurately.
The ACORD 25 form, which is a general liability application, also bears resemblance to the ACORD 130. Both forms are essential in the insurance application process, gathering information about the applicant's business operations, prior insurance history, and risk factors. While the ACORD 25 focuses on general liability coverage, the ACORD 130 is tailored for workers' compensation. The similarities in structure and required information help create a cohesive process for businesses applying for insurance across multiple lines of coverage.