› Supported document types › USA - ACORD Form 130 Workers Compensation Application

USA - ACORD Form 130 Workers Compensation Application

The Association for Cooperative Operations Research and Development (ACORD) forms are standardized documents used by the insurance industry.

This form is the standard, comprehensive form used by insurance agents to collect essential business, payroll, and loss history data to underwrite, rate, and bind worker's compensation insurance policies. It captures key details such as employee roles, remuneration by class code, and ownership information.

This form is supported for machine-printed documents only.

Supported versions: 2017/05

Supported fields on this form:

  • Date

  • Producer_Name

  • Cs_Representative_Name

  • Producer_Office_Phone

  • Producer_Mobile_Phone

  • Producer_Fax

  • Producer_Email

  • Agency_Customer_Id

  • Agency_Code

  • Agency_Sub_Code

  • Agency_Name

  • Agency_Address

  • Applicant_Name

  • Company

  • UnderWriter

  • Applicant_Id_Number

  • Federal_Employer_Id_Number

  • Employer_Registration_Number

  • Ncci_Risk_Id_Number

  • Sic_Code

  • Naics_Code

  • Years_In_Business

  • Applicant_Entity_Type_Sole_Proprietor

  • Applicant_Entity_Type_Corporation

  • Applicant_Entity_Type_LLC

  • Applicant_Entity_Type_Trust

  • Applicant_Entity_Type_Unincorporated_Association

  • Applicant_Entity_Type_Partnership

  • Applicant_Entity_Type_Subchapterscorp

  • Applicant_Entity_Type_Joint_Venture

  • Applicant_Entity_Type_Others

  • Applicant_Entity_Type_OthersText

  • Applicant_Entity_Type_Credit_Bureau_Name

  • Applicant_Mailing_Address

  • Applicant_Website

  • Applicant_Email

  • Applicant_Office_Phone

  • Applicant_Mobile_Phone

  • Status_Of_Submission_Quote

  • Status_Of_Submission_Bound

  • Status_Of_Submission_Assigned_Risk

  • Status_Of_Submission_Issue_Policy

  • Status_Of_Submission_Date

  • Locations_Table A table with the following columns

    • LOC

    • HighestFloor

    • StreetCityCountyStateZipCode

  • BillingSubmission_Information_Billing_Agency_Bill

  • BillingSubmission_Information_Billing_Direct_Bill

  • BillingSubmission_Information_Payment_Plan_Annual

  • BillingSubmission_Information_Payment_Plan_SemiAnnual

  • BillingSubmission_Information_Payment_Plan_Quarterly

  • BillingSubmission_Information_Payment_Plan_Others

  • BillingSubmission_Information_Payment_Plan_Percent_Down_Payment

  • BillingSubmission_Information_Audit_Type_AtExpiration

  • BillingSubmission_Information_Audit_Type_SemiAnnual

  • BillingSubmission_Information_Audit_Type_Quarterly

  • BillingSubmission_Information_Audit_Type_Monthly

  • BillingSubmission_Information_Audit_Type_Others

  • BillingSubmission_Information_Audit_Type_OthersText

  • Policy_Information_Proposed_Effective_Date

  • Policy_Information_Proposed_Expiration_Date

  • Policy_Information_Rating_Effective_Date

  • Policy_Information_Normal_Anniversary_Rating_Date

  • Policy_Information_Participating

  • Policy_Information_NonParticipating

  • Policy_Information_Retro_Plan

  • Policy_Information_Deductible_Medical

  • Policy_Information_Deductible_Indemnity

  • Policy_Information_Deductible_Others

  • Policy_Information_Deductible_Amount_Percent

  • Policy_Information_Other_Coverages_Uslh

  • Policy_Information_Other_Coverages_Voluntary_Comp

  • Policy_Information_Other_Coverages_Foreign_Coverage

  • Policy_Information_Other_Coverages_Managed_Care_Option

  • Policy_Information_Other_Coverages_Other1

  • Policy_Information_Other_Coverages_OtherText1

  • Policy_Information_Other_Coverages_Other2

  • Policy_Information_Other_Coverages_OtherText2

  • Policy_Information_States_Part1_Workers_Compensation

  • Policy_Information_States_Part3_Other_States

  • Policy_Information_Employers_Liability_Each_Accident

  • Policy_Information_Employers_Liability_Disease_Policy_Limit

  • Policy_Information_Employers_Liability_Disease_Each_Employee

  • Policy_Information_Dividend_Safety_Group

  • Policy_Information_Additional_Company_Information

  • Policy_Information_Specify_Additional_Coverages

  • Total_Estimated_Annual_Premium_All_States

  • Total_Minimum_Premium_All_States

  • Total_Deposit_Premium_All_States

  • ContactInformation_Table A table with the following columns:

    • Type

    • Name

    • OfficePhone

    • MobilePhone

    • Email

  • IndividualsIncludedExcluded_Table A table with the following columns:

    • State

    • LOC

    • Name

    • DateOfBirth

    • Title_Relationship

    • Ownerships

    • Duties

    • INC_EXC

    • ClassCode

    • Remuneration_Payroll

  • State_Rating_Sheet_StartSheet

  • State_Rating_Sheet_TotalSheets

  • State_Rating_Sheet_State

  • StateRatingWorksheet_Table A table with the following columns:

    • LOC

    • ClassCode

    • DescrCode

    • Categories_Duties_Classifications

    • FullTime

    • PartTime

    • SIC

    • NAICS

    • EstimatedAnnualRemuneration_Payroll

    • Rate

    • EstimatedAnnualManualPremium

    Premium_Table A table with the following columns:

    • State

    • Factor

    • FactoredPremium

  • Premium_Total_Estimated_Annual_Premium

  • Premium_Total_Minimum_Premium

  • Premium_Total_Deposit_Premium

  • PriorCarrierInformation_LossRunAttached

  • PriorCarrierInformation_Table A table with the following columns:

    • Year

    • Carrier

    • PolicyNumber

    • AnnualPremium

    • MOD

    • Claims

    • AmountPaid

    • Reserve

  • Remarks_1

  • Nature_Of_Business

  • General_Information_Owns_Aircraft_Watercraft_YorN

  • General_Information_Owns_Aircraft_Watercraft

  • General_Information_Hazardous_Materials_Operations_YorN

  • General_Information_Hazardous_Materials_Operations

  • General_Information_Underground_Work_YorN

  • General_Information_Underground_Work

  • General_Information_Work_On_Bridge_Over_Water_YorN

  • General_Information_Work_On_Bridge_Over_Water

  • General_Information_Applcant_Engaged_Other_Type_Of_Business_YorN

  • General_Information_Applcant_Engaged_Other_Type_Of_Business

  • General_Information_Subcontractors_Used_YorN

  • General_Information_Subcontractors_Used

  • General_Information_Work_Without_Certificates_Of_Insurance_YorN

  • General_Information_Work_Without_Certificates_Of_Insurance

  • General_Information_Written_Safety_Program_YorN

  • General_Information_Written_Safety_Program

  • General_Information_Group_Transportation_YorN

  • General_Information_Group_Transportation

  • General_Information_Employees_Under_16_Or_Over_60_YorN

  • General_Information_Employees_Under_16_Or_Over_60

  • General_Information_Seasonal_Employees_YorN

  • General_Information_Seasonal_Employees

  • General_Information_Volunteer_Or_Donated_Labor_YorN

  • General_Information_Volunteer_Or_Donated_Labor

  • General_Information_Employees_With_Physical_Handicaps_YorN

  • General_Information_Employees_With_Physical_Handicaps

  • General_Information_Employees_Travel_Out_Of_State_YorN

  • General_Information_Employees_Travel_Out_Of_State

  • General_Information_Athletic_Teams_Sponsored_YorN

  • General_Information_Athletic_Teams_Sponsored

  • General_Information_Physicals_Required_After_Offers_Of_Employment_YorN

  • General_Information_Physicals_Required_After_Offers_Of_Employment

  • General_Informtion_Other_Insurance_With_Insurer_YorN

  • General_Informtion_Other_Insurance_With_Insurer

  • General_Information_Prior_Coverage_Declined_YorN

  • General_Information_Prior_Coverage_Declined

  • General_Information_Employees_Health_Plans_Provided_YorN

  • General_Information_Employees_Health_Plans_Provided

  • General_Information_Employees_Work_For_Other_Businesses_YorN

  • General_Information_Employees_Work_For_Other_Businesses

  • General_Information_Employees_Leasing_YorN

  • General_Information_Employees_Leasing

  • General_Information_Employees_Work_From_Home_YorN

  • General_Information_Employees_Work_From_Home

  • General_Information_Tax_Liens_Or_Bankruptcy_Last_5Years_YorN

  • General_Information_Tax_Liens_Or_Bankruptcy_Last_5Years

  • General_Information_Unpaid_Workers_Premium_Due_YorN

  • General_Information_Unpaid_Workers_Premium_Due

  • Remarks_2

  • Signature_Copy_Of_The_Notice

  • Applicant_Signature

  • Applicant_Signature_Date

  • Producer_Signature

  • National_Producer_Number

  • Applicant_Initials