ACORD 130: Workers Compensation Application

Identification

Agency and carrier details plus full applicant information: legal name, mailing address, FEIN, entity type, years in business, and the NCCI risk ID if the account has one. The 130 does not borrow this from an ACORD 125, so complete all of it.

Watch for: Phrases like 'et al.' in the named insured. Every legal entity gets named, each with its own FEIN where one exists.

Status of submission

Whether you want a quote, an issued policy, or are confirming bound coverage. Assigned risk business checks its box here and adds the ACORD 133.

Billing and audit

Agency bill or direct bill, the payment plan, any down payment on bound business, and how often the carrier should audit.

Locations

Every workplace, numbered, with physical street addresses. The rating section keys to these numbers.

Watch for: Post office boxes. Underwriters and auditors need to know where work actually happens.

Policy information

Proposed effective and expiration dates, the Part 1 states where the applicant operates, Part 2 employers liability limits, and Part 3 other states coverage for places operations might reach during the term. Deductible elections and extras like USL&H and voluntary compensation go here too.

Watch for: Leaving Part 3 blank for a business that crosses state lines. If employees might work in a state mid-term, it belongs in Part 3.

Rating information

Class code, a description of duties, employee counts, and estimated annual remuneration for each classification, entered by state and location. Payroll means money and substitutes for money, so meals and lodging count when provided.

Watch for: Lowballing payroll. The audit finds it, and the additional premium lands months later at the worst possible time.

Premium calculations

Experience modification, schedule credits or debits, increased limits factors, and the running math down to total estimated annual premium and deposit.

Watch for: An experience mod entered from memory. Attach the current rating sheet; a stale mod misprices the whole quote.

Individuals included or excluded

Owners, partners, and executive officers, with ownership percentage, duties, and whether each elects in or out of coverage. State law controls who may elect what, so this section must be fully completed.

Watch for: Marking an officer excluded without checking the state's rules. Elections are state-specific and change both coverage and premium.

Prior carrier and loss history

Five years of carriers, policy numbers, premiums, mods, claim counts, and amounts paid and reserved, or attach loss runs and check the box instead.

Watch for: History that does not match the attached loss runs. Underwriters reconcile them line by line.

Nature of business and description of operations

What the business does at each location, in enough detail to classify it. A manufacturer describes raw materials, process, and products; a contractor describes the work performed and what gets subbed out.

Watch for: Copying classification phraseology from the manual. 'Metal Goods Mfg. NOC' tells the underwriter nothing; describe the actual product.

General information questions

Two dozen yes/no underwriting questions: aircraft and watercraft, hazardous materials, work at height or underground, subcontractors and their certificates, employees traveling out of state, group transportation, and more. Every yes gets an explanation in remarks.

Contact information and signatures

Named contacts for the physical inspection, the accounting records, and claims, plus the applicant's and producer's signatures.

Watch for: Unsigned applications. Quoting may proceed; binding will not.