Acord 130 Form Fillable (Workers Compensation Application)

Why is the ACORD 130 Fillable Form Important?

This form generally streamlines the application process and is a key component in providing information to the insurance carrier. It helps the insurer assess the risk, determine coverage, and calculate premiums. Moreover, the following scenarios will help you understand its importance.

Accurate Risk Assessment

Insurance companies need the information provided on this form to assess business-related risks. Accurate and transparent information helps ensure full coverage and calculate premiums. 

Legal Compliance

Most states require this form for worker’s compensation insurance for businesses. Fortunately, this form meets the legal criteria that secures the mandatory coverage.

Claims Management

This form simplifies the insurance claim process for workplace injuries. Effective and accurate data help the insurer process the claim smoothly, which is beneficial for both employees and employers.

How To Get Fillable ACORD 130 Workers Compensation Application Form?

Contact Insurance Agent

You may contact your insurance agent and arrange a meeting. Ask for a workers’ compensation application form. Provide all the comprehensive details about the nature of the business and employees. He/she will develop this form under the Association for Cooperative Operations Research and Development (ACORD) policy. Note: This form is not required in all states of the United States.

Official Website

You can quickly access this form through Acord’s official website. Visit the homepage, type the form by number or keyword, and press the search button. Then, click the download button to save this form on your device.

Third-Party Website

You can also visit third-party websites such as Forms Dude. To visit the homepage, type www.formsdude.com in the Google search bar. Then, press the “Insurance Forms” icon to see the forms page. Type the form’s name (Acord 130 Form) and press the download button to save it quickly.

Step-by-Step Instructions for Filling Out the Blank Acord 130 Form

The following instructions will help you to fill out this form effectively:

1- Company Information

Write in the first section of the form the full name of the company, underwriter name, applicant name, office phone number, mobile phone number, mailing address including zip code, NAIC (National Association of Insurance Commissioners) number, and email address.

2- Agency Details

In this section, write the agency name and address, the producer’s name, the CS representative’s name, office phone number, mobile phone number, fax number, code, subcode, and customer ID number.

3- Billing Information

Please check the status submission boxes in this section and attach the Acord 133 for assigned risk. Also, check the boxes for the billing, payment, and audit plans.

4- Locations

Write the location number, floor name, street, city, county, state, and postal code in this section.

5- Policy Information

Write comprehensive details about the policy, including the effective date, expiration date, retro plan, worker’s compensation state, employer’s liability, deductibles, and other coverages.

6- Estimated Annual Premiums

Write the amount of total estimated annual premiums in all states.

7- Contact Details

Write the name, office phone number, mobile number, and email address for different types, including inspection, account record, and claims information.

8- Individuals Included/Excluded

In this section, write the name, date of birth, relationship, ownership percentage, duties, included or excluded, class code, and payroll details of all partners, officers, and relatives who are company employees.

9- State Rating Sheet

You need to attach this sheet page for multiple states. In this sheet, write the location number, class code, description code, categories, full-time and part-time employees’ numbers, and payroll details.

10- Premium

In this section, write the amount of the premium including additional details. Also, write the total estimated annual, minimum, and deposit premium.

11- Loss History

In this section, write loss details with remarks of the last 5 years.

12- General Information

Explain all the questions about the policy coverage in “Yes” or No.”

13- Remarks and Signature

Write additional remarks about the policy and get the signature of the applicant and producer with the date.

Additional Details to Consider While Filling Out Acord 130 Form

The following additional details are essential to consider for accurate completion of the form:

Incomplete Information

You must write the complete information for every required field in the form. Incomplete information may cause delays in the application process.

Misclassification of Employees

Writing the accurately assigned class code of the employees consulting with the agent is essential. The incorrect codes may cause under or overpayment of the premiums.

Incorrect Payroll Estimates

You must write the exact payroll information of the employees to protect them from high costs during the audit.

Unreported Loss History

It is also essential to provide the loss history details for the last five years to avoid coverage issues or cancellations.

FAQs

What is the Acord 130 Form Used for?

It is a legal form developed under the Association for Cooperative Operations Research and Development policy to apply for worker’s compensation insurance. Insurers often use it to assess risk and calculate premiums in case of workplace injury.

What Information is Required on the Acord 130?

It requires the basic information of the producer, company, and applicant, as well as business details, payroll estimates, loss history, employee classification, and coverage limits.

How Long Does it Take to Complete the Acord 130 Application?

If you have all the relevant documents and information, the process usually takes 1 to 2 hours to complete. However, if your business is more complex, it may take longer.

What if My Business Has No Prior Claims?

To avoid high-cost premiums, you must indicate the “Clean Loss History” in the relevant section.