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ACORD Form 130 Workers Compensation
Application Instructions

 

 
ACORD 130 (2007/11) 1 of 38
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 10/07/2008.
Section Name Field Name Field and/or Section Description
TITLE ACORD 130 (2007/11) Workers Compensation Application The title of the form. The ACORD 130 - Workers Compensation Application is a self-contained Commercial Lines application that does not require the completion of the Applicant Information Section (ACORD 125). Therefore, complete the entire Identification section of this form. The Workers Compensation Application provides for workers' compensation, employer's liability, and voluntary compensation coverages. The Policy Information section has been designed to follow workers' compensation rules published by the National Council on Compensation Insurance (NCCI). Other plans may be used with this form as well. Please refer to the NCCI manual for coverage definitions. This form may not be used in Florida. Refer to Florida Workers Compensation Application, ACORD 130 FL.
IDENTIFICATION Date (MM/DD/YYYY) Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION Agency Name and Address Enter text: The producer's full name.
IDENTIFICATION Enter text: The producer's mailing address line one.
IDENTIFICATION Enter text: The producer's mailing address line two.
IDENTIFICATION Enter text: The producer's mailing address city name.
IDENTIFICATION Enter code: The producer's mailing address state or province code.
IDENTIFICATION Enter code: The producer's mailing address postal code.
IDENTIFICATION Producer Name Enter text: The name of the individual at the producer's establishment that is the primary contact.
IDENTIFICATION CS Representative Enter text: The name of the customer service representative of the producer.
IDENTIFICATION Office Phone (A/C, no, ext) Enter number: The producer's contact person's phone number. As used here, this is the office phone number.
IDENTIFICATION Mobile Phone Enter number: The producer's contact person's cell phone number.
IDENTIFICATION Fax (A/C, no) Enter number: The fax number of the producer.
IDENTIFICATION E-mail Address Enter text: The producer's contact person e-mail address.
IDENTIFICATION Code Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer.
IDENTIFICATION Subcode Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage).

ACORD 130 (2007/11) 2 of 38

Section Name Field Name Field and/or Section Description
IDENTIFICATION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION Company Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. This is not the insurer's group name or trade name.
IDENTIFICATION Underwriter Enter text: The company underwriter that this application should be directed to.
IDENTIFICATION Applicant Name Enter text: The named insuredís full name as it appears on the policy declarations page.
IDENTIFICATION Office Phone Enter number: The named insured's primary phone number. As used here, this is the office phone number.
IDENTIFICATION Mobile Phone Enter number: The named insured's secondary phone number. As used here, this is the cell phone number.
IDENTIFICATION Mailing Address Enter text: The named insured's mailing address line one.
IDENTIFICATION Enter text: The named insured's mailing address line two.
IDENTIFICATION Enter text: The named insured's mailing address city name.
IDENTIFICATION Enter code: The named insured's mailing address state or province code.
IDENTIFICATION Enter code: The named insured's mailing address postal code.
IDENTIFICATION Years in Business Enter number: The number of years the insured has been in business.
IDENTIFICATION SIC Enter code: The Standard Industry Classification code assigned to the business activity (if known).
IDENTIFICATION NAICS Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity (if known).
IDENTIFICATION Website Address Enter text: The primary website address for the named insured.
IDENTIFICATION E-Mail Address Enter text: The named insured's primary e-mail address.
IDENTIFICATION Type of Business Organization -Sole Proprietor Check the box (if applicable): Indicates the legal entity code for the named insured is "Sole Proprietor".
IDENTIFICATION Partnership Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership".
IDENTIFICATION Corporation Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation".
IDENTIFICATION Subchapter "S" Corporation Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation".
IDENTIFICATION LLC Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation".
IDENTIFICATION Joint Venture Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture".

ACORD 130 (2007/11) 3 of 38

Section Name Field Name Field and/or Section Description
IDENTIFICATION Trust Check the box (if applicable): Indicates the legal entity code for the named insured is "Trust".
IDENTIFICATION Other Check the box (if applicable): Indicates the legal entity code for the named insured is not listed on the form.
IDENTIFICATION Credit Bureau Name Enter text: The code identifies an external source that may be used to provide financial or credit information. For example, a Dun and Bradstreet Number, TRW number, Equifax, Trans-Union, etc.
IDENTIFICATION ID Number Enter identifier: The identifier assigned by the credit bureau for the risk.
IDENTIFICATION Federal Employer ID Number Enter identifier: The tax identifier of the named insured. As used here, this is the Federal Employer Identification Number.
IDENTIFICATION NCCI Risk ID Number Enter identifier: The nine-digit number assigned to the insured by the National Council on Compensation Insurance (NCCI). This number is required in most states before a policy can be issued. It also helps insure timely and accurate calculation of experience modifications. The NCCI is a rating bureau operating in most states that also provides interstate experience rating for risks occurring in more than one state.
IDENTIFICATION Other Rating Bureau ID or State Employer Registration Number Enter identifier: The state's rating bureau may assign a separate identification number if the applicant is subject to experience rating in an independent bureau state. In Minnesota, use this box to record the insured's unemployment account number, as required by the state. In New Jersey, use this box to record the insured's state employer registration number.
STATUS OF SUBMISSION Quote Check the box (if applicable): Indicates the response expected from the company is a quote.
STATUS OF SUBMISSION Bound Check the box (if applicable): Indicates the coverage has been bound. As used here, include the date coverage began and attach a copy of the binder. This application is not a substitute for a binder. You may check more than one box (e.g., if the underwriter indicated by telephone that the risk is acceptable and coverage can be bound, check both Bound and Issue).
STATUS OF SUBMISSION Bound Date Enter date: The effective date of the binder.
STATUS OF SUBMISSION Assigned Risk Check the box (if applicable): Indicates the response expected from the company is an assigned risk policy. For Assigned Risk business check the "Assigned Risk" box and complete an ACORD 133 Workers Compensation Insurance Plan Assigned Risk Section. Rules for binding assigned risk policies apply. The Quote, Issue Policy and Bound options do not apply when submitting an assigned risk application. Please refer to the instructions for the ACORD 133 for specific uses of the ACORD 130 elements as they apply to assigned risk business.

ACORD 130 (2007/11) 4 of 38

Section Name Field Name Field and/or Section Description
Check the box (if applicable): Indicates the response expected from the company is an
STATUS OF SUBMISSION Issue Policy issued policy.
BILLING/AUDIT
INFORMATION Billing Plan - Agency Bill Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
BILLING/AUDIT
INFORMATION Direct Bill Check the box (if applicable): Indicates if the policy is to be direct billed.
BILLING/AUDIT
INFORMATION Payment Plan - Annual Check the box (if applicable): Indicates the policy will be paid annually.
BILLING/AUDIT
INFORMATION Semi-Annual Check the box (if applicable): Indicates the policy will be paid semi-annually.
BILLING/AUDIT
INFORMATION Quarterly Check the box (if applicable): Indicates the policy will be paid quarterly.
BILLING/AUDIT Check the box (if applicable): Indicates the policy will be paid in a frequency other than
INFORMATION Other those listed.
BILLING/AUDIT
INFORMATION Other Description Enter code: The payment plan for the policy.
BILLING/AUDIT Enter percentage: The percentage of the total estimated annual premium that has been
INFORMATION % Down (or will be) received as a down payment for bound policies.
BILLING/AUDIT Check the box (if applicable): Indicates audits should be performed for this policy at
INFORMATION Audit - At Expiration expiration.
BILLING/AUDIT Check the box (if applicable): Indicates audits should be performed for this policy semi-
INFORMATION Semi-Annual annually.
BILLING/AUDIT Check the box (if applicable): Indicates audits should be performed for this policy
INFORMATION Quarterly quarterly.
BILLING/AUDIT
INFORMATION Monthly Check the box (if applicable): Indicates audits should be performed for this policy monthly.
BILLING/AUDIT Check the box (if applicable): Indicates audits should be performed for this policy at a
INFORMATION Other frequency other than those listed.
Enter code: The audit term for policies that are subject to periodic audit. If the audit period
BILLING/AUDIT is known, enter the code; A - annual, S - semi-annual, Q - Quarterly, M - Monthly, O -
INFORMATION Other Description Other.
LOCATIONS Number (#) Enter number: The producer assigned number of the location.
Street, City, County, State, Zip
LOCATIONS Code Enter text: The first address line of the location.
LOCATIONS Enter text: The second address line of the location.
LOCATIONS Enter text: The city of the location.

ACORD 130 (2007/11) 5 of 38

Section Name Field Name Field and/or Section Description
LOCATIONS Enter text: The county of the location.
LOCATIONS Enter code: The state or province of the location.
LOCATIONS Enter code: The postal code of the location.
LOCATIONS Number (#) Enter number: The producer assigned number of the location.
LOCATIONS Street, City, County, State, Zip Code Enter text: The first address line of the location.
LOCATIONS Enter text: The second address line of the location.
LOCATIONS Enter text: The city of the location.
LOCATIONS Enter text: The county of the location.
LOCATIONS Enter code: The state or province of the location.
LOCATIONS Enter code: The postal code of the location.
LOCATIONS Number (#) Enter number: The producer assigned number of the location.
LOCATIONS Street, City, County, State, Zip Code Enter text: The first address line of the location.
LOCATIONS Enter text: The second address line of the location.
LOCATIONS Enter text: The city of the location.
LOCATIONS Enter text: The county of the location.
LOCATIONS Enter code: The state or province of the location.
LOCATIONS Enter code: The postal code of the location.
POLICY INFORMATION Proposed Policy Eff Date Enter date: The effective date of the policy. As used here, the date on which the terms and conditions of the policy will commence. For assigned risk business being submitted with the ACORD 133 use the effective date on that form, following state mandated rules.
POLICY INFORMATION Proposed Exp date Enter date: The date on which the terms and conditions of the policy will expire. As used here, the date on which the terms and conditions of the policy will expire. The normal policy period (effective date to expiration date) is one year. However, a policy may be issued for any length of time up to a maximum of three years. Certain rules and endorsements must be used if the policy is written for more than one year. It may be necessary to use Effective and Expiration Dates that do not indicate a one year term, to concur with other policies.

ACORD 130 (2007/11) 6 of 38

Section Name Field Name Field and/or Section Description
POLICY INFORMATION Normal Anniversary Rating Date Enter date: The rates used are normally in effect on the effective date of the policy. NCCI Manual rules require that the rates apply for a period of one year. If a policy is cancelled or short-termed, the rating bureau requires the original effective date to be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is temporary and will last until the next renewal when the new policy effective date will again determine the rates. The rule is intended to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For cancelled or short-termed polices, enter the original effective date.
POLICY INFORMATION Participating/Non-Participating Check the box (if applicable): Indicates the policy is a participating policy. A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating basis. Check with your company on the availability of plans.
POLICY INFORMATION Non-Participating Check the box (if applicable): Indicates the policy is a non-participating policy.
POLICY INFORMATION Retro Plan Enter text: The retrospective rating plan that permits the adjustment of the final premium based on the actual premiums and losses of the applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check with your company on the availability of plans.
POLICY INFORMATION Part 1 Workers Compensation (States) Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.

ACORD 130 (2007/11) 7 of 38

Section Name Field Name Field and/or Section Description
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the insured has operations.
POLICY INFORMATION Part 2 - Employers Liability - Each Accident Enter limit: The workers compensation and employers liability policy, employers liability each accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
POLICY INFORMATION Disease-Policy Limit Enter limit: The workers compensation and employers liability policy, employers liability disease policy limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
POLICY INFORMATION Disease-Each Employee Enter limit: The workers compensation and employers liability policy, employers liability disease each employee limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
POLICY INFORMATION Part 3 - Other States Insurance Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.

ACORD 130 (2007/11) 8 of 38

Section Name Field Name Field and/or Section Description
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Enter code: A state in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy.
POLICY INFORMATION Deductibles - Medical Check the box (if applicable): Indicates the deductible type is Medical in the state where coverage is being applied for. (In Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.)
POLICY INFORMATION Indemnity Check the box (if applicable): Indicates the deductible type is Indemnity in the state where coverage is being applied for. (In Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.)
POLICY INFORMATION Other Check the box (if applicable): Indicates the deductible type is other than those listed.
POLICY INFORMATION Other Description Enter text: The description of the deductible type.
POLICY INFORMATION Amount / % Enter amount: The amount of the deductible as a whole dollar amount or as a percentage. For percentages indicate the percentage amount followed by the percent (%) sign.
POLICY INFORMATION Other Coverages - U.S.L. & H. Check the box (if applicable): Indicates United States Longshoremen's & Harbor Worker's (USL&H) coverage is requested. Exposures for this optional coverages as well as additional coverages should be described in the Specify Additional Coverages/Endorsements section.

ACORD 130 (2007/11) 9 of 38

Section Name Field Name Field and/or Section Description
Check the box (if applicable): Indicates Voluntary Compensation coverage is requested.
Exposures for this optional coverages as well as additional coverages should be described
POLICY INFORMATION Voluntary Comp in the Specify Additional Coverages/Endorsements section.
Check the box (if applicable): Indicates Foreign coverage is requested. Exposures for this
optional coverages as well as additional coverages should be described in the Specify
POLICY INFORMATION Foreign Cov Additional Coverages/Endorsements section.
Check the box (if applicable): Indicates Managed Care Option is requested. Exposures
for this optional coverages as well as additional coverages should be described in the
POLICY INFORMATION Managed Care Option Specify Additional Coverages/Endorsements section.
Check the box (if applicable): Indicates other coverages than those listed are being
POLICY INFORMATION Other requested.
POLICY INFORMATION Other Description Enter text: The description of the coverage being requested.
Check the box (if applicable): Indicates other coverages than those listed are being
POLICY INFORMATION Other requested.
POLICY INFORMATION Other Description Enter text: The description of the coverage being requested.
Enter text: The specific plan or safety group of which the insured is a member. This field is
POLICY INFORMATION Dividend Plan or Safety Group related to the participating plan. Check with your company on the availability of plans.
Enter text: The additional company or state specific information should be listed in this
POLICY INFORMATION Additional Company Information section.
Specify Additional Enter text: The description of exposures for the optional coverages selected in the Other
POLICY INFORMATION Coverages/Endorsements Coverages section. Any additional coverages should also be described.
TOTAL ESTIMATED
ANNUAL PREMIUM - ALL Total Estimated Annual Premium Enter amount: The amount resulting from applying all modifications, discounts, taxes and
STATE All States other rating criteria to the total estimated pre-modified premium for all states.
TOTAL ESTIMATED
ANNUAL PREMIUM - ALL
STATE Total Minimum Premium All States Enter amount: Total minimum premium required by company rules for all states.
TOTAL ESTIMATED
ANNUAL PREMIUM - ALL
STATE Total Deposit Premium All States Enter amount: Total amount of deposit required by company rules for all states.
Enter text: The name of the person to contact to arrange for a premises inspection. This
should be an individual under the insured's employment, not the insurance agent's name
CONTACT INFORMATION Inspection (Name) and number.

ACORD 130 (2007/11) 10 of 38

Section Name Field Name Field and/or Section Description
Enter number: The telephone number of the person to contact to arrange for a premises
inspection. This should be an individual under the insured's employment. As used here,
CONTACT INFORMATION Inspection (Office Phone) this is the office phone number.
Enter number: The cell phone number of the person to contact to arrange for a premises
CONTACT INFORMATION Inspection (Mobile Phone) inspection. This should be an individual under the insured's employment.
Enter text: The e-mail address (if applicable) of the person to contact to arrange for a
premises inspection. This should be an individual under the insured's employment, not
CONTACT INFORMATION Inspection (E-Mail Address) the insurance agent's name and number.
Enter text: The name of the person to contact for accounting information. This should be
CONTACT INFORMATION Accounting Records (Name) an individual under the insured's employment, not the insurance agent.
Enter number: The telephone number of the person to contact for accounting information.
Accounting Records (Office This should be an individual under the insured's employment, not the insurance agent's
CONTACT INFORMATION Phone) name and number. As used here, this is the office phone number.
Accounting Records (Mobile
CONTACT INFORMATION Phone) Enter number: The cell phone number of the person to contact for accounting information.
Enter text: The e-mail address (if applicable) of the person to contact for accounting
Accounting Records (E-Mail information. This should be an individual under the insured's employment, not the
CONTACT INFORMATION Address) insurance agent's name and number.
Enter text: The full name of the person the insurer is to contact regarding any potential
CONTACT INFORMATION Claims Information (Name) claims inquiries.
Enter number: The telephone number of the person the insurer is to contact regarding any
CONTACT INFORMATION Claims Information (Office Phone) potential claims inquiries. As used here, this is the office phone number.
Enter number: The cell phone number of the person the insurer is to contact regarding any
CONTACT INFORMATION Claims Information (Mobile Phone) potential claims inquiries.
Claims Information (E-Mail Enter text: The e-mail address (if applicable) of the person the insurer is to contact
CONTACT INFORMATION Address) regarding any potential claims inquiries.
INDIVIDUALS
INCLUDED/EXCLUDED State Enter code: The state in which the individual's payroll developed.
INDIVIDUALS
INCLUDED/EXCLUDED LOC # Enter number: The producer assigned location number for the individual.
INDIVIDUALS Enter text: The full name of the partner, executive officer or relative being included or
INCLUDED/EXCLUDED Name excluded by the policy.
INDIVIDUALS
INCLUDED/EXCLUDED Date of Birth Enter date: The individual's birth date.

ACORD 130 (2007/11) 11 of 38

Section Name Field Name Field and/or Section Description
INDIVIDUALS INCLUDED/EXCLUDED Title/Relationship Enter code: The individual's title within the organization or relationship to the organization's owners.
INDIVIDUALS INCLUDED/EXCLUDED Ownership % Enter percentage: The percentage of ownership the individual has in the organization, if applicable.
INDIVIDUALS INCLUDED/EXCLUDED Duties Enter text: The brief description of the duties of the individual.
INDIVIDUALS INCLUDED/EXCLUDED Inc/Exc Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages.
INDIVIDUALS INCLUDED/EXCLUDED Class Code Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only.
INDIVIDUALS INCLUDED/EXCLUDED Remuneration/Payroll Enter amount: The estimated annual remuneration for individuals to be included. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals).
INDIVIDUALS INCLUDED/EXCLUDED State Enter code: The state in which the individual's payroll developed.
INDIVIDUALS INCLUDED/EXCLUDED LOC # Enter number: The producer assigned location number for the individual.
INDIVIDUALS INCLUDED/EXCLUDED Name Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy.
INDIVIDUALS INCLUDED/EXCLUDED Date of Birth Enter date: The individual's birth date.
INDIVIDUALS INCLUDED/EXCLUDED Title/Relationship Enter code: The individual's title within the organization or relationship to the organization's owners.
INDIVIDUALS INCLUDED/EXCLUDED Ownership % Enter percentage: The percentage of ownership the individual has in the organization, if applicable.
INDIVIDUALS INCLUDED/EXCLUDED Duties Enter text: The brief description of the duties of the individual.
INDIVIDUALS INCLUDED/EXCLUDED Inc/Exc Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages.
INDIVIDUALS INCLUDED/EXCLUDED Class Code Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only.

ACORD 130 (2007/11) 12 of 38

Section Name Field Name Field and/or Section Description
INDIVIDUALS INCLUDED/EXCLUDED Remuneration/Payroll Enter amount: The estimated annual remuneration for individuals to be included. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals).
INDIVIDUALS INCLUDED/EXCLUDED State Enter code: The state in which the individual's payroll developed.
INDIVIDUALS INCLUDED/EXCLUDED LOC # Enter number: The producer assigned location number for the individual.
INDIVIDUALS INCLUDED/EXCLUDED Name Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy.
INDIVIDUALS INCLUDED/EXCLUDED Date of Birth Enter date: The individual's birth date.
INDIVIDUALS INCLUDED/EXCLUDED Title/Relationship Enter code: The individual's title within the organization or relationship to the organization's owners.
INDIVIDUALS INCLUDED/EXCLUDED Ownership % Enter percentage: The percentage of ownership the individual has in the organization, if applicable.
INDIVIDUALS INCLUDED/EXCLUDED Duties Enter text: The brief description of the duties of the individual.
INDIVIDUALS INCLUDED/EXCLUDED Inc/Exc Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages.
INDIVIDUALS INCLUDED/EXCLUDED Class Code Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only.
INDIVIDUALS INCLUDED/EXCLUDED Remuneration/Payroll Enter amount: The estimated annual remuneration for individuals to be included. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals).
INDIVIDUALS INCLUDED/EXCLUDED State Enter code: The state in which the individual's payroll developed.
INDIVIDUALS INCLUDED/EXCLUDED LOC # Enter number: The producer assigned location number for the individual.
INDIVIDUALS INCLUDED/EXCLUDED Name Enter text: The full name of the partner, executive officer or relative being included or excluded by the policy.
INDIVIDUALS INCLUDED/EXCLUDED Date of Birth Enter date: The individual's birth date.

ACORD 130 (2007/11) 13 of 38

Section Name Field Name Field and/or Section Description
INDIVIDUALS INCLUDED/EXCLUDED Title/Relationship Enter code: The individual's title within the organization or relationship to the organization's owners.
INDIVIDUALS INCLUDED/EXCLUDED Ownership % Enter percentage: The percentage of ownership the individual has in the organization, if applicable.
INDIVIDUALS INCLUDED/EXCLUDED Duties Enter text: The brief description of the duties of the individual.
INDIVIDUALS INCLUDED/EXCLUDED Inc/Exc Enter code: Indicates if the individual is to be Included or Excluded under the policy's coverages.
INDIVIDUALS INCLUDED/EXCLUDED Class Code Enter code: The rating classification code that the individual's estimated remuneration was assigned to for included individuals only.
INDIVIDUALS INCLUDED/EXCLUDED Remuneration/Payroll Enter amount: The estimated annual remuneration for individuals to be included. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
STATE RATING WORKSHEET State Rating Sheet # of Sheets Enter number: The chronological number of the state rating sheet out of a total number of sheets.
STATE RATING WORKSHEET Total Number of Sheets Enter number: The total number of state rating sheets.
STATE RATING WORKSHEET Rating Information State: Enter text: The name of the state to which the rating information is applicable.
STATE RATING WORKSHEET LOC # Enter number: The producer assigned number of the location.
STATE RATING WORKSHEET Class Code Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used.
STATE RATING WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.

ACORD 130 (2007/11) 14 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 15 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 16 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 17 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 18 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 19 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 20 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 21 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 22 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 23 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 24 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 25 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 26 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
STATE RATING
WORKSHEET LOC # Enter number: The producer assigned number of the location.
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
STATE RATING from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
WORKSHEET Class Code may be used.
STATE RATING
WORKSHEET Description Code Enter code: The company description code for this type of risk (if applicable).
STATE RATING WORKSHEET Categories, Duties, Classifications Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
Enter number: The number of full time employees to whom the classification applies. The
STATE RATING average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Full Time Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 130 (2007/11) 27 of 38

Section Name Field Name Field and/or Section Description
Enter number: The number of part time employees to whom the classification applies.
STATE RATING The average number is sufficient when the total number fluctuates during the year.
WORKSHEET No. of Employees, Part Time Underwriters use this number to determine if the payroll estimates appear adequate
STATE RATING Enter code: The Standard Industry Class code assigned to the particular type of business
WORKSHEET SIC (if known).
STATE RATING Enter code: The North American Industry Classification System (NAICS) 6-digit industry
WORKSHEET NAICS code assigned to the particular type of business (if known).
STATE RATING WORKSHEET Estimated Annual Remuneration/Payroll Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
STATE RATING
WORKSHEET Rate Enter rate: The manual rate for the classification from the appropriate state manual.
STATE RATING
WORKSHEET Estimated Annual Manual Premium Enter amount: The estimated manual premium amount for the classification.
PREMIUM State Enter text: The name of the state to which the rating information is applicable.
Enter amount: The total estimated pre-modified premium amount obtained by adding the
PREMIUM Total amounts for each class.
Enter rate: The factor is used to calculate the total estimated annual premium. Agents
PREMIUM Total - Factor completing the rating process should fill out this section of the application.
PREMIUM Total - Factored Premium Enter amount: The total premium amount.
Enter rate: The modification factor if limits other than the standard limits for Part 2
PREMIUM Increased Limits - Factor Employers Liability are requested.
increased Limits - Factored
PREMIUM Premium Enter amount: The modified premium amount.
PREMIUM Deductible - Factor Enter rate: The deductible factor if a state deductible option is available and chosen.
PREMIUM Deductible - Factored Premium Enter amount: The modified premium amount.
Enter text: The description of optional factors, charges or credits that are required or
PREMIUM Optional Line (Blank Space) applicable.
Enter rate: The modification factor for optional factors, charges or credits that are required
PREMIUM Factor or applicable.
PREMIUM Factored Premium Enter amount: The modified premium amount.

ACORD 130 (2007/11) 28 of 38

Section Name Field Name Field and/or Section Description
PREMIUM Experience or Merit Modification -Factor Enter rate: The modification factor if the insured is subject to experience or merit rating. Generally the business has to have been in operation for at least two years under present ownership and the premium must meet or exceed a level which is established by the state to qualify for experience or merit rating. If more than one modification factor applies to the applicant, explain in the Remarks section. Attach the most recent experience or merit rating data sheet.
PREMIUM Experience or Merit Modification -Factored Premium Enter amount: The modified premium amount.
PREMIUM Optional Line (Blank Space) Enter text: The description of optional factors, charges or credits that are required or applicable.
PREMIUM Factor Enter rate: The modification factor for optional factors, charges or credits that are required or applicable.
PREMIUM Factored Premium Enter amount: The modified premium amount.
PREMIUM Assigned Risk Surcharge - Factor Enter rate: The modification factor for assigned risk policy surcharge. A state specific surcharge may apply for placement of business into an assigned risk pool.
PREMIUM Assigned Risk Surcharge -Factored Premium Enter amount: The modified premium amount.
PREMIUM ARAP - Factor Enter rate: The modification factor for assigned risk adjustment program (ARAP). A state specific adjustment for assigned risk policies.
PREMIUM ARAP - Factored Premium Enter amount: The modified premium amount.
PREMIUM Optional Line (Blank Space) Enter text: The description of optional factors, charges or credits that are required or applicable.
PREMIUM Factor Enter rate: The modification factor for optional factors, charges or credits that are required or applicable.
PREMIUM Factored Premium Enter amount: The modified premium amount.
PREMIUM Schedule Rating - Factor Enter rate: The modification factor for schedule rating (if applicable).
PREMIUM Schedule Rating - Factored Premium Enter amount: The modified premium amount.
PREMIUM CCPAP - Factor Enter rate: The modification factor for the contracting class premium adjustment program (CCPAP). Not applicable in all states.
PREMIUM CCPAP - Factored Premium Enter amount: The modified premium amount.
PREMIUM Standard Premium - Factor Enter rate: The modification factor for the total premium before applying premium discount.
PREMIUM Standard Premium - Factored Premium Enter amount: The modified premium amount.

ACORD 130 (2007/11) 29 of 38

Section Name Field Name Field and/or Section Description
Enter rate: The modification factor for premium discount. A premium discount may be
PREMIUM Premium Discount - Factor applicable due to large premium levels.
Premium Discount - Factored
PREMIUM Premium Enter amount: The modified premium amount.
Enter amount: The modified premium amount including the flat amount of the expense
PREMIUM Expense Constant constant as applicable per the state rating manual.
Enter amount: The modified premium amount including state taxes and assessments
PREMIUM Taxes/Assessments applicable.
Enter text: The description of optional factors, charges or credits that are required or
PREMIUM Optional Line (Blank Space) applicable.
Enter rate: The modification factor for optional factors, charges or credits that are required
PREMIUM Factor or applicable.
PREMIUM Factored Premium Enter amount: The modified premium amount.
Enter amount: The amount resulting from applying all modifications, discounts, taxes and
PREMIUM Total Estimated Annual Premium other rating criteria to the estimated pre-modified premium for this state.
PREMIUM Minimum Premium Enter amount: The minimum premium amount required by company rules for this state.
PREMIUM Deposit Premium Enter amount: The amount of deposit required by rules for this state.
REMARKS Remarks Enter text: The remarks associated with the state.
Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION Agency Customer ID agency or brokerage).
PRIOR CARRIER
INFORMATION/LOSS
HISTORY Loss Run Attached Check the box (if applicable): Indicates a loss run is attached to this policy.
PRIOR CARRIER
INFORMATION/LOSS
HISTORY Year Enter year: The year the prior coverage policy term became effective.
PRIOR CARRIER
INFORMATION/LOSS
HISTORY Co Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION/LOSS
HISTORY Pol # Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER
INFORMATION/LOSS Enter amount: The annual modified premium charged (not including taxes or service
HISTORY Annual Premium charges) for the specified line of business.

ACORD 130 (2007/11) 30 of 38

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION/LOSS HISTORY Mod Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual.
PRIOR CARRIER INFORMATION/LOSS HISTORY # Claims Enter date: The total number of claims for the corresponding policy period.
PRIOR CARRIER INFORMATION/LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
PRIOR CARRIER INFORMATION/LOSS HISTORY Reserve Enter amount: The reserve amount the previous carrier is holding open for this claim.
PRIOR CARRIER INFORMATION/LOSS HISTORY Year Enter year: The year the prior coverage policy term became effective.
PRIOR CARRIER INFORMATION/LOSS HISTORY Co Enter text: The name of the previous insurer.
PRIOR CARRIER INFORMATION/LOSS HISTORY Pol # Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER INFORMATION/LOSS HISTORY Annual Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business.
PRIOR CARRIER INFORMATION/LOSS HISTORY Mod Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual.
PRIOR CARRIER INFORMATION/LOSS HISTORY # Claims Enter date: The total number of claims for the corresponding policy period.
PRIOR CARRIER INFORMATION/LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
PRIOR CARRIER INFORMATION/LOSS HISTORY Reserve Enter amount: The reserve amount the previous carrier is holding open for this claim.

ACORD 130 (2007/11) 31 of 38

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION/LOSS HISTORY Year Enter year: The year the prior coverage policy term became effective.
PRIOR CARRIER INFORMATION/LOSS HISTORY Co Enter text: The name of the previous insurer.
PRIOR CARRIER INFORMATION/LOSS HISTORY Pol # Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER INFORMATION/LOSS HISTORY Annual Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business.
PRIOR CARRIER INFORMATION/LOSS HISTORY Mod Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual.
PRIOR CARRIER INFORMATION/LOSS HISTORY # Claims Enter date: The total number of claims for the corresponding policy period.
PRIOR CARRIER INFORMATION/LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
PRIOR CARRIER INFORMATION/LOSS HISTORY Reserve Enter amount: The reserve amount the previous carrier is holding open for this claim.
PRIOR CARRIER INFORMATION/LOSS HISTORY Year Enter year: The year the prior coverage policy term became effective.
PRIOR CARRIER INFORMATION/LOSS HISTORY Co Enter text: The name of the previous insurer.
PRIOR CARRIER INFORMATION/LOSS HISTORY Pol # Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER INFORMATION/LOSS HISTORY Annual Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business.

ACORD 130 (2007/11) 32 of 38

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION/LOSS HISTORY Mod Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual.
PRIOR CARRIER INFORMATION/LOSS HISTORY # Claims Enter date: The total number of claims for the corresponding policy period.
PRIOR CARRIER INFORMATION/LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
PRIOR CARRIER INFORMATION/LOSS HISTORY Reserve Enter amount: The reserve amount the previous carrier is holding open for this claim.
PRIOR CARRIER INFORMATION/LOSS HISTORY Year Enter year: The year the prior coverage policy term became effective.
PRIOR CARRIER INFORMATION/LOSS HISTORY Co Enter text: The name of the previous insurer.
PRIOR CARRIER INFORMATION/LOSS HISTORY Pol # Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER INFORMATION/LOSS HISTORY Annual Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business.
PRIOR CARRIER INFORMATION/LOSS HISTORY Mod Enter percentage: The reciprocal of the percentage by which the premium shown differs from the manual.
PRIOR CARRIER INFORMATION/LOSS HISTORY # Claims Enter date: The total number of claims for the corresponding policy period.
PRIOR CARRIER INFORMATION/LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
PRIOR CARRIER INFORMATION/LOSS HISTORY Reserve Enter amount: The reserve amount the previous carrier is holding open for this claim.

ACORD 130 (2007/11) 33 of 38

Section Name Field Name Field and/or Section Description
Enter text: The text description of the operations of this risk or insured. As used here, this
section informs the underwriter of each applicant's business and the way it is conducted
by premises. Operations, which may not be apparent in a general description, may be
segmented by location. For example, location #1 may be the general offices while location
#2 may be the warehouse. The section should include enough detail to enable the
underwriter to understand and classify each operation. Do not use the classification
phraseology from the Commercial Lines Manual or Workers' Compensation Manual,
NATURE OF because they do not provide adequate detail.
BUSINESS/DESCRIPTION Nature of Business / Description of For example, a manufacturer of pulley wheels used in sewing machines should be
OF OPERATIONS Operations described as such and not as "Metal Goods Mfg. N.O.C."
1. Does applicant own, operate or Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant
GENERAL INFORMATION lease aircraft/watercraft? own, operate or lease aircraft or watercraft?".
Enter text: An explanation of a response to a general information or underwriting question.
GENERAL INFORMATION Remarks Normally, "Yes" responses require an explanation.
Check the box (if applicable): Indicates a "No" response to the question, "Does applicant
GENERAL INFORMATION No own, operate or lease aircraft or watercraft?".
GENERAL INFORMATION 2. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g., landfills, wastes, fuel tanks, etc.) Check the box (if applicable): Indicates a "Yes" response to the question, "Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?".
Enter text: An explanation of a response to a general information or underwriting question.
GENERAL INFORMATION Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION No Check the box (if applicable): Indicates a "No" response to the question, "Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?".
3. Any work performed Check the box (if applicable): Indicates a "Yes" response to the question, "Any work
GENERAL INFORMATION underground or above 15 feet? performed underground or above 15 feet?".
Enter text: An explanation of a response to a general information or underwriting question.
GENERAL INFORMATION Remarks Normally, "Yes" responses require an explanation.
Check the box (if applicable): Indicates a "No" response to the question, "Any work
GENERAL INFORMATION No performed underground or above 15 feet?".

ACORD 130 (2007/11) 34 of 38

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION 4. Any work performed on barges, vessels, docks or bridge over water? Check the box (if applicable): Indicates a "Yes" response to the question, "Is work performed on barges, vessels, docks, bridge over water?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION No Check the box (if applicable): Indicates a "No" response to the question, "Is work performed on barges, vessels, docks, bridge over water?".
GENERAL INFORMATION 5. Is applicant engaged in any other type of business? Check the box (if applicable): Indicates a "Yes" response to the question, "Is applicant engaged in any other type of business?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION No Check the box (if applicable): Indicates a "No" response to the question, "Is applicant engaged in any other type of business?".
GENERAL INFORMATION 6. Are subcontractors used? Check the box (if applicable): Indicates a "Yes" response to the question, "Are subcontractors used?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION No Check the box (if applicable): Indicates a "No" response to the question, "Are subcontractors used?".
GENERAL INFORMATION 7. Any work sublet without certificates of insurance? Check the box (if applicable): Indicates a "Yes" response to the question, "Any work sublet without certificates of insurance?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION No Check the box (if applicable): Indicates a "No" response to the question, "Any work sublet without certificates of insurance?".
GENERAL INFORMATION 8. Is a written safety program in operation? Check the box (if applicable): Indicates a "Yes" response to the question, "Is a written safety program in operation?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION No Check the box (if applicable): Indicates a "No" response to the question, "Is a written safety program in operation?".
GENERAL INFORMATION 9. Any group transportation provided? Check the box (if applicable): Indicates a "Yes" response to the question, "Any group transportation provided?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.

ACORD 130 (2007/11) 35 of 38

Section Name Field Name Field and/or Section Description
Check the box (if applicable): Indicates a "No" response to the question, "Any group
GENERAL INFORMATION No transportation provided?".
10. Any employees under 16 or Check the box (if applicable): Indicates a "Yes" response to the question, "Any employees
GENERAL INFORMATION over 60 years of age? under 16 or over 60 years of age?".
Enter text: An explanation of a response to a general information or underwriting question.
GENERAL INFORMATION Remarks Normally, "Yes" responses require an explanation.
Check the box (if applicable): Indicates a "No" response to the question, "Any employees
GENERAL INFORMATION No under 16 or over 60 years of age?".
Check the box (if applicable): Indicates a "Yes" response to the question, "Any seasonal
GENERAL INFORMATION 11. Any seasonal employees? employees?".
Enter text: An explanation of a response to a general information or underwriting question.
GENERAL INFORMATION Remarks Normally, "Yes" responses require an explanation.
Check the box (if applicable): Indicates a "No" response to the question, "Any seasonal
GENERAL INFORMATION No employees?".
12. Is there any volunteer or Check the box (if applicable): Indicates a "Yes" response to the question, "Is there any
GENERAL INFORMATION donated labor? volunteer or donated labor?".
Enter text: An explanation of a response to a general information or underwriting question.
GENERAL INFORMATION Remarks Normally, "Yes" responses require an explanation.
Check the box (if applicable): Indicates a "No" response to the question, "Is there any
GENERAL INFORMATION No volunteer or donated labor?".
Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION Agency Customer ID agency or brokerage).
GENERAL INFORMATION 13. Any employees with physical Check the box (if applicable): Indicates a "Yes" response to the question, "Any employees
(continued) handicaps? with physical handicaps?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Any employees
(continued) No with physical handicaps?".
GENERAL INFORMATION 14. Do employees travel out of Check the box (if applicable): Indicates a "Yes" response to the question, "Do employees
(continued) state? travel out of state?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Do employees
(continued) No travel out of state?".
GENERAL INFORMATION Check the box (if applicable): Indicates a "Yes" response to the question, "Are athletic
(continued) 15. Are athletic teams sponsored? teams sponsored?".

ACORD 130 (2007/11) 36 of 38

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Are athletic
(continued) No teams sponsored?".
GENERAL INFORMATION 16. Are physicals required after Check the box (if applicable): Indicates a "Yes" response to the question, "Are physicals
(continued) offers of employment are made? required after offers of employment are made?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Are physicals
(continued) No required after offers of employment are made?".
GENERAL INFORMATION 17. Any other insurance with this Check the box (if applicable): Indicates a "Yes" response to the question, "Any other
(continued) insurer? insurance with this company?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Any other
(continued) No insurance with this company?".
18. Any prior coverage Check the box (if applicable): Indicates a "Yes" response to the question, "Any policy or
GENERAL INFORMATION declined/cancelled/non-renewed in coverage declined, cancelled or non-renewed during the mandated number of years (Not
(continued) last three (3) years? applicable in Missouri)?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
Check the box (if applicable): Indicates a "No" response to the question, "Any policy or
GENERAL INFORMATION coverage declined, cancelled or non-renewed during the mandated number of years (Not
(continued) No applicable in Missouri)?".
GENERAL INFORMATION 19. Are employee health plans Check the box (if applicable): Indicates a "Yes" response to the question, "Is there an
(continued) provided? Employee Health Plan provided?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Is there an
(continued) No Employee Health Plan provided?".
20. Do any employees perform
GENERAL INFORMATION work for other businesses or Check the box (if applicable): Indicates a "Yes" response to the question, "Do any
(continued) subsidiaries? employees perform work for other businesses or subsidiaries?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.

ACORD 130 (2007/11) 37 of 38

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Do any
(continued) No employees perform work for other businesses or subsidiaries?".
GENERAL INFORMATION 21. Do you lease employees to or Check the box (if applicable): Indicates a "Yes" response to the question, "Do you lease
(continued) from other employers ? employees to or from other employers?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Do you lease
(continued) No employees to or from other employers?".
GENERAL INFORMATION 22. Do any employees Check the box (if applicable): Indicates a "Yes" response to the question, "Do employees
(continued) predominantly work at home? predominantly work from home?".
GENERAL INFORMATION
(continued) If "YES", # of employees: Enter number: The number of employees that predominantly work from home.
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Do employees
(continued) No predominantly work from home?".
GENERAL INFORMATION 23. Any tax liens or bankruptcy Check the box (if applicable): Indicates a "Yes" response to the question, "Any tax liens or
(continued) within the last five (5) years? bankruptcy within the past mandated number of years?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Check the box (if applicable): Indicates a "No" response to the question, "Any tax liens or
(continued) No bankruptcy within the past mandated number of years?".
24. Any undisputed and unpaid
workers compensation premium Check the box (if applicable): Indicates a "Yes" response to the question, "Any undisputed
GENERAL INFORMATION due from you or any company and unpaid workers compensation premium due from you or any commonly managed or
(continued) managed or owned enterprises? owned enterprises?".
GENERAL INFORMATION Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
Check the box (if applicable): Indicates a "No" response to the question, "Any undisputed
GENERAL INFORMATION and unpaid workers compensation premium due from you or any commonly managed or
(continued) No owned enterprises?".
REMARKS Remarks Enter text: The remarks associated with the Workers Compensation line of business.
SIGNATURE Applicant's Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Date Enter date: The date the form was signed by the named insured.
Section Name Field Name Field and/or Section Description
SIGNATURE Producer's Signature Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates.
SIGNATURE National Producer Number Enter identifier: The National Producer Insurance Producer Registry Number of the producer.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).

ACORD 130 (2007/11) 38 of 38