Fast PDF Templates
Homepage / Blank Acord 130 Form
Structure

Misconceptions

Misconceptions about the ACORD 130 form can lead to confusion and errors in the application process. Here are five common misconceptions:

  • The ACORD 130 form is only for large businesses. Many believe this form is only necessary for large corporations. In reality, it is required for businesses of all sizes that need workers' compensation insurance.
  • Filling out the ACORD 130 form is optional. Some may think that this form is optional. However, it is a crucial part of the application process for obtaining workers' compensation coverage.
  • All information on the ACORD 130 form is confidential. While the form collects sensitive information, not all details are kept private. Certain data may be shared with insurance companies or regulatory agencies as part of the underwriting process.
  • The ACORD 130 form is the same across all states. Many assume that the form is uniform in every state. However, specific requirements and additional forms may vary by state, so it is essential to check local regulations.
  • Once submitted, the ACORD 130 form cannot be changed. Some individuals believe that any errors or omissions are permanent after submission. In fact, applicants can update or amend the form if necessary before the policy is finalized.

Detailed Steps for Filling Out Acord 130

Filling out the ACORD 130 form is an important step in applying for workers' compensation insurance. This form collects essential information about your business, including its structure, operations, and coverage needs. Make sure to have all relevant details ready before you start. Here’s how to fill it out step by step:

  1. Enter the Date: Fill in the date of application in the format MM/DD/YYYY.
  2. Agency Information: Write down the agency name and address.
  3. Company Details: Provide the name of the insurance company and the underwriter.
  4. Applicant Information: Fill in your name, office phone, mobile phone, and mailing address, including ZIP code.
  5. Business Information: Indicate the number of years in business and enter the SIC and NAICS codes.
  6. Producer Information: Write the producer's name, office phone, and email address.
  7. Business Structure: Check the appropriate box for your business type (e.g., Sole Proprietor, Corporation, LLC).
  8. Contact Information: Provide a contact name, office phone, mobile phone, and email for inspection, accounting, or claims information.
  9. Policy Information: Fill in the proposed effective and expiration dates, along with the normal anniversary rating date.
  10. Coverage Details: Specify the coverage amounts for workers' compensation, employer's liability, and any other relevant details.
  11. Estimated Premium: Enter the total estimated annual premium and any minimum or deposit premiums.
  12. Employee Information: List individuals included or excluded from coverage, including their relationship to the business.
  13. Loss History: Provide details about prior carriers and any claims history for the past five years.
  14. General Information: Answer all yes/no questions honestly and provide explanations where necessary.
  15. Signature: The authorized representative must sign and date the form, confirming the accuracy of the information provided.

After completing the form, review all entries for accuracy. Make sure to keep a copy for your records before submitting it to your insurance agent or broker. This ensures that you have a reference for any future inquiries or updates.

Document Preview

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:

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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

 

 

 

 

$

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

Common PDF Templates

Erc Bma - The report highlights the necessity of marketing incentives to boost buyer interest.

Printable Roofing Certificate of Completion - This overview highlights the importance of accurate roofing documentation for insurance.

Dos and Don'ts

When filling out the ACORD 130 form, careful attention to detail is essential. Here are some dos and don’ts to keep in mind:

  • Do ensure that all fields are completed accurately. Missing information can delay processing.
  • Do double-check the dates you enter. Use the correct format (MM/DD/YYYY) to avoid confusion.
  • Do provide clear and concise descriptions of your business operations. This helps insurers assess risk accurately.
  • Do include all relevant contact information for yourself and your agency. This facilitates communication.
  • Don’t leave out any required signatures. An unsigned form can lead to rejection.
  • Don’t provide false or misleading information. This can have serious legal consequences.
  • Don’t forget to review the form before submission. Errors can lead to delays or complications in your coverage.

Key takeaways

Understanding the Acord 130 Form is essential for anyone applying for workers' compensation insurance. Here are four key takeaways to keep in mind:

  • Accurate Information is Crucial: Ensure all fields are filled out accurately. This includes details about the applicant, business operations, and insurance history. Inaccuracies can lead to delays or issues with coverage.
  • Include All Employees: Clearly list all employees, including partners and relatives, who are included or excluded from coverage. This information affects premium calculations and compliance with state regulations.
  • Understand Coverage Options: Familiarize yourself with the different parts of the form that address various coverages, such as workers' compensation and employer's liability. Knowing what is included helps in making informed decisions about your insurance needs.
  • Review Loss History: Provide a comprehensive loss history for the past five years. This includes any claims made and the details surrounding them. Insurers use this information to assess risk and determine premiums.

Similar forms

The ACORD 125 form is a similar document used in the insurance industry. It serves as a general insurance application that collects essential information about the applicant and their insurance needs. Like the Acord 130, the ACORD 125 gathers details about the agency, applicant, and type of coverage desired. It also includes sections for underwriting information, which helps insurers assess risk and determine appropriate premiums. Both forms streamline the application process by ensuring that all necessary information is captured in a standardized format.

The ACORD 133 form is specifically designed for assigned risk plans. This document is similar to the Acord 130 in that it collects vital information regarding the applicant's business and its insurance requirements. The ACORD 133 focuses on businesses that may not qualify for standard coverage due to high-risk factors. Just as the Acord 130 does, the ACORD 133 requires detailed information about the business operations, employee classifications, and loss history, allowing insurers to evaluate the risk effectively.

The ACORD 140 form is another relevant document that deals with commercial property insurance. It gathers information about the property to be insured, including its location, occupancy, and safety features. Like the Acord 130, the ACORD 140 requires detailed descriptions to assist insurers in determining coverage limits and premiums. Both forms emphasize the importance of accurate and comprehensive data to ensure that the applicant receives appropriate coverage tailored to their specific needs.

The ACORD 141 form is used for general liability insurance applications. This document shares similarities with the Acord 130 by requesting essential information about the business, including its operations and any previous claims history. Both forms aim to provide insurers with a clear picture of the applicant's risk profile. By collecting this information, the ACORD 141 helps insurers assess the potential liability exposure and set premiums accordingly.

Lastly, the ACORD 151 form is used for auto insurance applications. It parallels the Acord 130 in its purpose of gathering necessary information to assess risk and provide coverage. The ACORD 151 focuses on vehicle details, driver information, and any previous claims. Both forms require thorough and accurate data to ensure that applicants receive the appropriate insurance coverage for their specific situations. This standardization helps streamline the underwriting process across various types of insurance applications.

Documents used along the form

The ACORD 130 form is a critical document used in the application process for workers' compensation insurance. It gathers essential information about the applicant's business and its operations. However, several other forms and documents are often utilized alongside the ACORD 130 to ensure a comprehensive understanding of the applicant's insurance needs. Below is a list of these commonly used forms, each with a brief description.

  • ACORD 133: This form is used to provide additional information when applying for workers' compensation insurance, especially for applicants classified as assigned risk. It details the nature of the business and the types of coverage needed.
  • ACORD 101: The Additional Remarks Schedule allows the applicant to provide further explanations or details that may not fit within the confines of the primary application. This can include additional coverages or special circumstances regarding the business.
  • ACORD 25: This is a certificate of insurance that serves as proof of coverage. It outlines the types of insurance the applicant holds and is often requested by clients or partners to verify that adequate coverage is in place.
  • ACORD 126: This form is used to provide information about the applicant's general liability insurance. It complements the workers' compensation application by detailing liability coverage that may be necessary for the business.
  • Loss Run Report: This document summarizes the claims history of the applicant over a specified period, usually the past five years. It is crucial for insurers to assess risk and determine premium rates.
  • Employer's Liability Insurance Application: This application is specifically for obtaining employer's liability insurance, which protects businesses against claims made by employees for work-related injuries not covered by workers' compensation.
  • State-Specific Workers' Compensation Forms: Different states may have unique forms or requirements for workers' compensation applications. These documents ensure compliance with state regulations and may include additional information specific to that jurisdiction.
  • Business Operations Description: A detailed description of the business operations helps insurers understand the nature of the work being performed. This information is critical for accurately assessing risk and determining coverage needs.
  • Payroll Records: Accurate payroll records are essential for calculating premiums for workers' compensation insurance. They provide a clear picture of employee classifications and total payroll amounts, which influence the overall cost of coverage.

In summary, while the ACORD 130 form is a vital component of the workers' compensation application process, it is often accompanied by various other forms and documents. Each of these plays a significant role in ensuring that the insurance application is complete and that the coverage provided meets the specific needs of the business. Understanding these additional requirements can help facilitate a smoother application process and ensure adequate protection for both the employer and employees.