ACORD Forms
ACORD 133: Workers Compensation Insurance Plan Assigned Risk Section
The ACORD 133 is the assigned risk supplement for workers comp. When an account cannot get coverage in the voluntary market and has to go through a state workers compensation insurance plan, the 133 attaches to a completed ACORD 130. The form says it plainly: the 133 along with a 130 constitutes the application for assigned risk coverage, and the 133 must be attached to a 130 for submission. It never travels alone.
What it is
The ACORD 133 is the assigned risk supplement for workers comp. When an account cannot get coverage in the voluntary market and has to go through a state workers compensation insurance plan, the 133 attaches to a completed ACORD 130. The form says it plainly: the 133 along with a 130 constitutes the application for assigned risk coverage, and the 133 must be attached to a 130 for submission. It never travels alone.
It exists because assigned risk plans ask questions the voluntary market does not: coverage gaps, unpaid premium, common ownership, PEO arrangements, and trucking operations. Plan reviewers work from what is on the page. Missing answers turn into rejections and resubmissions, and the effective date slips with them.
When it's used
- Workers comp submissions to a state assigned risk plan or WCIP after the voluntary market declines the account, always attached to a completed ACORD 130.
- New ventures with no coverage history that cannot yet get voluntary quotes.
- Classes the voluntary market avoids: trucking, temporary labor, or accounts with prior premium disputes.
Section-by-section walkthrough
Applicant and effective date
The applicant name and proposed effective date, matching the attached ACORD 130 exactly.
Watch for: A name or date that disagrees with the 130. The two forms are one application, so any mismatch reads as an error.
Payroll office information
The name, street address, and phone number of the office where payroll records are kept. The form warns that a PO box alone is not acceptable, and asks for driving instructions if a rural route address is used.
Watch for: Listing only a PO box. The plan's auditor needs a physical place to inspect payroll records.
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.
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.
Watch for: Leaving the why blank when there is no prior coverage. The form asks for the reason, and the plan will not guess.
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.
Watch for: Undisclosed ownership changes. Experience mods follow ownership, and the rating bureau connects entities the application did not.
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.
Watch for: Treating an old dispute as resolved when it is still open. Plans check, and unpaid premium can block the application.
PEO and leased workers
Whether the applicant leases workers from a professional employer organization, leases workers to client companies, or provides temporary labor. Each yes points to specific WCIP instructions or attachments.
Watch for: Answering no because the arrangement is informal. If someone else's payroll is on the applicant's job sites, it belongs here.
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.
Watch for: Skipping the block because it looks optional. If trucking classifications apply, the whole set is required, including the driver list.
Remarks
Explanations for every yes answer. The form instructs that all yes responses get explained in the remarks section.
Watch for: A yes with no remark. That is the single fastest way to get an assigned risk application kicked back.
In Relay
ACORD Generation is live in Relay. It drafts the ACORD 133 from the client record and the documents you already have, and a person reviews every field before anything goes out. See how →
Common errors
- A PO box as the payroll office address. The form requires a physical address where payroll records can be examined.
- Yes answers with no explanation in remarks.
- The 133 submitted without a completed ACORD 130 attached, which the form itself says is required.
- Ownership changes in the past five years left undisclosed, which forces an ERM-14 conversation after the fact.
- State specific plan requirements ignored. The form points to a state specific instructions page for a reason: each plan has its own rules.
Common questions
Can I submit an ACORD 133 by itself?
No. The form states it must be attached to an ACORD 130, and that the two together constitute the application for assigned risk coverage. Complete the 130 first, then the 133.
Is the ACORD 133 the same in every state?
The form is standard and contains material copyrighted by NCCI, which administers many state plans. Requirements still vary by state, and the form directs you to a state specific instructions page. Check the plan's instructions before submitting.
Can Relay draft the ACORD 133?
ACORD Generation is live in Relay. It drafts ACORD forms from the client record and documents you already have, and a person reviews everything before it goes out.
Part of the Relay ACORD form library. Updated 2026-07-11. See how we source content.
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