ACORD 130: Workers Compensation Application
ACORD 130 is the Workers Compensation Application. It includes applicant information together with workplaces, operations, payroll, classifications, and requested policy details.
What it is
ACORD 130 is the Workers Compensation Application. It includes applicant information together with workplaces, operations, payroll, classifications, and requested policy details.
Prepare it from current payroll estimates, ownership information, workplace details, available rating information, and loss records. Rules and forms vary by jurisdiction and rating authority, so confirm the requirements for the states in the submission.
When it's used
- A workers compensation market accepts ACORD 130.
- An account needs payroll and operations organized by state and classification.
- An assigned risk process requests it with the applicable additional section.
Section-by-section walkthrough
Identification
Agency, carrier, and applicant information, including legal names, addresses, entity details, and the identifiers requested by the market.
Review check: Verify legal entities and identifiers.
Status of submission
The transaction requested, such as a quote or policy issuance, with any applicable assigned risk designation.
Review check: Mark the requested transaction accurately.
Billing and audit
Agency bill or direct bill, the payment plan, any down payment on bound business, and how often the carrier should audit.
Review check: Confirm billing and audit details.
Locations
Every workplace, numbered, with physical street addresses. The rating section keys to these numbers.
Review check: Identify actual workplaces.
Policy information
Proposed dates, state coverage information, employers liability limits, and additional elections required for the requested program.
Review check: Review state coverage needs with the market.
Rating information
Classifications, duties, employee counts, and estimated remuneration by state and location. Use the applicable rules for what belongs in each amount.
Review check: Use current payroll, classifications, periods, and units.
Premium calculations
Experience modification, schedule credits or debits, increased limits factors, and the running math down to total estimated annual premium and deposit.
Review check: Verify the modification and premium inputs.
Individuals included or excluded
Owners, partners, or officers and the information and elections required for the applicable jurisdictions.
Review check: Confirm state-specific owner and officer requirements.
Prior carrier and loss history
Prior carriers, policy details, and loss information for the period the form or market requests.
Review check: Match the requested history to loss sources.
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.
Review check: Describe actual duties and operations.
General information questions
The questions on operations, employees, subcontracting, travel, and other exposures. Supply explanations as the form and market require.
Review check: Follow the instructions for each question.
Contact information and signatures
Named contacts for the physical inspection, the accounting records, and claims, plus the applicant's and producer's signatures.
Review check: Provide appropriate contacts and signatures.
In Relay
Relay can prepare supported ACORD drafts from the documents you provide. This reference guide explains ACORD 130; it is not a promise that this form or edition is available in your workspace. Check the supported form, then review the fields and missing answers before use. See how →
Common errors
- Mixing payroll periods or classification bases.
- Using an outdated experience modification.
- Assuming owner elections or other-states treatment are the same everywhere.
Common questions
Do we also need ACORD 125?
ACORD 130 includes its own applicant information. Confirm the market's complete packet, especially when other lines are being submitted.
How should we handle multistate work?
Identify where employees actually work and any expected changes. Confirm the relevant state, classification, coverage, and election requirements with the market or rating authority.
What changes for assigned risk?
Follow the applicable plan's current instructions, forms, eligibility, payment, and effective-date process. NCCI publishes state-specific instructions for plans it administers.
Related forms
Form references
- ACORD Forms Portal: current forms and authorized access
- ACORD-authored Forms Index, May 2024 (historical form names)
- NCCI: current assigned risk and state instruction resources
Confirm the form edition and requirements with the market receiving the submission.
Part of the Relay ACORD form library. Updated 2026-07-11. See how we source content.
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