Printable Acord 130 Form

• Understand the Purpose: The Acord 130 form is essential for applying for workers' compensation insurance, providing crucial information about your business and its operations.
• Complete All Sections: Ensure every section of the form is filled out accurately. Missing information can delay your application or result in coverage issues.
• Provide Accurate Contact Information: Include correct contact details for the agency, applicant, and any representatives. This helps streamline communication.
• Detail Your Business Operations: Clearly describe your business activities, including any subcontracting or special operations. This information is vital for risk assessment.
• Report Employee Information: List all employees accurately, including their roles and salaries. This affects your premium calculations.
• Be Honest About Past Claims: Provide a truthful account of any past claims or losses. This history can impact your eligibility and rates.
• Understand the Billing Options: Familiarize yourself with the different billing plans available, such as monthly or annual payments, to choose what works best for your business.
• Review Deductibles and Coverage: Carefully consider the deductibles and coverage options. Make sure they align with your business needs and financial capacity.
• Check for Additional Requirements: Some states may have specific requirements or forms to attach. Always verify what’s needed for your state.
• Keep a Copy: Retain a copy of the completed form for your records. This can be helpful for future applications or renewals.

What is the Acord 130 form?

The Acord 130 form is a Workers Compensation Application used by businesses in the United States to apply for workers' compensation insurance. This form collects essential information about the applicant, including their business structure, estimated payroll, and details about their operations. By providing this information, businesses enable insurance companies to assess their risk and determine appropriate coverage options and premiums.

Who needs to fill out the Acord 130 form?

Any business seeking workers' compensation insurance is required to complete the Acord 130 form. This includes various business structures such as sole proprietorships, corporations, partnerships, and limited liability companies (LLCs). Whether a business has employees or not, completing this form is crucial for obtaining coverage that protects against workplace injuries and related liabilities.

What information is required on the Acord 130 form?

The Acord 130 form requires comprehensive information, including the agency name and address, applicant name, business structure, contact information, and details about the business operations. Additionally, it asks for information regarding the number of employees, estimated payroll, prior insurance coverage, and loss history. Specific questions about potential risks, such as the use of subcontractors or hazardous materials, must also be answered.

How does the Acord 130 form impact insurance premiums?

The information provided on the Acord 130 form directly influences the calculation of insurance premiums. Insurers evaluate factors such as payroll estimates, business classification codes, and loss history to assess the level of risk associated with the applicant. A higher risk may result in increased premiums, while a lower risk could lead to more favorable rates. Accurate and complete information is essential to ensure that the premium reflects the true risk profile of the business.

Can the Acord 130 form be submitted electronically?

Yes, many insurance agencies and brokers allow the Acord 130 form to be submitted electronically. This option streamlines the application process and can facilitate quicker responses from insurance providers. However, it is important to confirm with the specific agency or insurer whether they accept electronic submissions and to follow their guidelines for completing and submitting the form.

What should be done if there are changes in business operations after submitting the Acord 130 form?

If there are significant changes in business operations after submitting the Acord 130 form, it is crucial to notify the insurance provider immediately. Changes such as an increase in the number of employees, new business activities, or alterations in risk exposure can affect coverage and premiums. Keeping the insurer informed ensures that the business remains adequately protected and compliant with insurance requirements.

Acord 130 - Usage Instruction

Filling out the ACORD 130 form is a straightforward process. Follow these steps carefully to ensure all necessary information is accurately provided. This form is essential for applying for workers' compensation insurance.

1. Enter the Date: Fill in the date of application in MM/DD/YYYY format.
2. Agency Information: Write the agency name and address where applicable.
3. Company Details: Provide the name of the insurance company and the underwriter.
4. Applicant Information: Complete the applicant's name, office phone, mobile phone, and mailing address (including ZIP + 4 or Canadian Postal Code).
5. Business Information: Indicate the number of years in business and the Standard Industrial Classification (SIC) code.
6. Producer Information: Fill in the producer’s name, North American Industry Classification System (NAICS) code, and contact details.
7. Business Structure: Mark the appropriate box for the type of business (e.g., sole proprietor, corporation, LLC, etc.).
8. Contact Information: Provide contact details for individuals involved, including their roles and phone numbers.
9. Policy Information: Enter the proposed effective and expiration dates, along with other policy-related details.
10. Coverage Details: Specify the coverage amounts and types, including workers' compensation and employer's liability.
11. Estimated Premiums: List total estimated annual premiums and any other financial details required.
12. Loss History: Provide information about prior carriers and loss history for the past five years.
13. General Information: Answer all questions regarding the business operations and any special circumstances.
14. Signature: Ensure the applicant's authorized representative signs and dates the form.

Once the form is completed, review all entries for accuracy. Submit it to your insurance agent or broker for processing. Be prepared to provide additional documentation if requested.