Table of Contents
The Acord 130 form plays a crucial role in the realm of workers' compensation insurance, serving as a comprehensive application that businesses must complete to secure coverage. This form captures essential information about the applicant, including their agency details, business structure, and contact information. It also requires specifics about the nature of the business operations, estimated payroll, and the number of employees. By detailing the history of any claims and prior insurance coverage, the Acord 130 helps insurers assess risk and determine appropriate premiums. Additionally, it includes sections for various coverage options, including employer's liability and optional endorsements, allowing businesses to tailor their insurance needs. Understanding how to accurately fill out this form can significantly impact a company's ability to obtain the right workers' compensation coverage, ensuring that both the business and its employees are protected in case of workplace injuries.
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Document Specifics
| Fact Name | Description |
|---|---|
| Purpose | The ACORD 130 form is used to apply for workers' compensation insurance coverage. |
| Application Date | Applicants must provide the date of application in MM/DD/YYYY format. |
| Contact Information | The form requires multiple contact details, including office and mobile phone numbers. |
| State-Specific Information | Each state may have specific requirements for the form, governed by local laws. |
| Employer Information | Details about the employer, such as type of business and employee classifications, are required. |
| Premium Estimates | Applicants must estimate their annual premium based on payroll and risk factors. |
How to Write Acord 130
Completing the ACORD 130 form involves providing specific information about your business and its workers' compensation needs. Follow these steps to fill out the form accurately.
- Enter the date in MM/DD/YYYY format at the top of the form.
- Fill in the agency name and address.
- Provide the company name and underwriter details.
- Enter the applicant name, office phone, and mobile phone.
- Complete the mailing address, including ZIP + 4 or Canadian Postal Code.
- Indicate the years in business and the SIC and NAICS codes.
- List the producer name and the customer service representative's contact information.
- Select the business structure (e.g., sole proprietor, corporation, etc.).
- Provide the credit ID number and federal employer ID number.
- Complete the policy information section, including proposed effective and expiration dates.
- Fill out the workers compensation and employer's liability sections.
- Provide details about additional company information and estimated annual premium.
- List individuals included or excluded from coverage, including their relationship and remuneration.
- Complete the prior carrier information and loss history section.
- Answer the general information questions, indicating any "yes" responses with explanations.
- Sign and date the form where indicated, ensuring the applicant is an authorized representative.
Dos and Don'ts
When filling out the Acord 130 form, there are some important guidelines to follow. Here’s a list of what you should and shouldn’t do:
- Do provide accurate and complete information. This ensures your application is processed smoothly.
- Don’t leave any required fields blank. Missing information can delay your application.
- Do double-check your contact information. Make sure your phone number and email are correct.
- Don’t omit any details about your business operations. Transparency helps in getting the right coverage.
- Do include all relevant employee information. This includes their roles and remuneration.
- Don’t rush through the application. Take your time to ensure everything is accurate.
Documents used along the form
The Acord 130 form is an essential document used in the process of applying for workers' compensation insurance. However, there are several other forms and documents that often accompany this application to ensure a comprehensive understanding of the applicant's business and insurance needs. Below are five commonly used forms that work in conjunction with the Acord 130.
- Acord 133: This form is used to provide additional information regarding the applicant's business operations, especially when applying for workers' compensation coverage under an assigned risk plan. It helps insurers assess the risk associated with the business more accurately.
- Non-Disclosure Agreement (NDA): A crucial document for protecting sensitive business information. For more details, visit https://floridaforms.net/blank-non-disclosure-agreement-form.
- Acord 101: This is the Additional Remarks Schedule. It allows applicants to include any extra information or comments that may not fit within the standard application forms. This can be crucial for clarifying details or providing context about specific business operations.
- Loss Run Report: This document outlines the applicant's claims history over a specified period, typically the last five years. Insurers use this report to evaluate the risk based on past claims, which can significantly impact premium rates.
- State Rating Worksheet: This worksheet provides detailed information about the classification of the business and its employees. It helps determine the appropriate premium rates based on the nature of the work performed and the associated risks.
- Certificate of Insurance: Often required by clients or partners, this document proves that the business has active workers' compensation coverage. It is essential for compliance and to maintain good business relationships.
By utilizing these forms alongside the Acord 130, businesses can present a well-rounded application that addresses all necessary aspects of their operations and insurance needs. This thoroughness can lead to better coverage options and potentially lower premiums.