ACORD 133: Workers Compensation Insurance Plan Assigned Risk Section
ACORD 133 is the Workers Compensation Insurance Plan Assigned Risk Section. It supplies additional information for an assigned risk application with ACORD 130 where the applicable plan uses those forms.
What it is
ACORD 133 is the Workers Compensation Insurance Plan Assigned Risk Section. It supplies additional information for an assigned risk application with ACORD 130 where the applicable plan uses those forms.
Prepare the main application first, then reconcile ownership, prior insurance, payroll records, and any plan-specific questions. Use the current state instructions for the plan administrator, rather than applying another state's requirements.
When it's used
- The applicable assigned risk plan requests ACORD 133 with ACORD 130.
- A submission needs the additional plan eligibility information.
- An existing packet is being checked against current plan instructions.
Section-by-section walkthrough
Applicant and effective date
The applicant name and proposed effective date, matching the attached ACORD 130 exactly.
Review check: Match the main application.
Payroll office information
The contact and physical location of payroll records, with the detail required by the current state instructions.
Review check: Identify the payroll records contact and location.
State developing highest payroll
The state where the applicant develops the most payroll, which matters for multi state operations entering a single state's plan.
Review check: Use the requested payroll state information.
Prior coverage history
Whether the applicant has had workers comp coverage in this state or any other, and if not, why: new business or self insurance.
Review check: Explain prior coverage accurately.
Ownership changes and related entities
Name changes, mergers, acquisitions, sales, and any entity related through common management or ownership, whether or not it needs coverage. These answers can require a completed ERM-14 experience rating form.
Review check: Disclose relevant ownership and entity changes.
Unpaid premium
Whether any workers comp premium is due or in dispute from the applicant or any commonly owned enterprise, with entity names and policy numbers if so.
Review check: Answer unpaid-premium questions based on current facts.
PEO and leased workers
PEO, leased-worker, and temporary-labor arrangements, with the additional information directed by the plan.
Review check: Describe PEO or labor arrangements accurately.
Trucking supplemental questions
If trucking classifications apply: terminal addresses, a list of drivers and helpers with residence states, the goods hauled, the hauling radius, and any exclusive contracts.
Review check: Complete applicable trucking information.
Remarks
The explanations and supporting details requested by the form and applicable state instructions.
Review check: Follow the form and state explanation instructions.
In Relay
Relay can prepare supported ACORD drafts from the documents you provide. This reference guide explains ACORD 133; 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
- Names or dates that disagree with ACORD 130.
- Omitting an ownership change or unresolved premium question.
- Assuming form completion establishes the binding date.
Common questions
Can ACORD 133 replace ACORD 130?
It is a supplemental section. Follow the plan's instructions for the full application and required attachments.
Are assigned risk requirements the same in every state?
No single form establishes that. Check the current instructions for the applicable administrator, including submission, payment, eligibility, and effective-date requirements.
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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