ACORD Form 133 Workers Compensation
Insurance Plan - Assigned Risk Instructions

 

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Section Name	Field Name	Field and/or Section Description
		Use ACORD 133, Workers Compensation Insurance Plan Assigned Risk Section, in conjunction with the ACORD Workers Compensation Application, ACORD 130. These two forms collect the data necessary for submitting assigned risk business.
		Please answer all questions thoroughly. Any omission may result in delay or denial of coverage. Where space restricts a complete answer, attach answer on a separate sheet of paper. These applications do not provide coverage.
		Refer to the National Council on Compensation Insurance Inc. (NCCI) WCIP State Instruction pages for state specific instructions on completing the ACORD 133 and ACORD 130 for WCIP business.
TITLE ACORD 133 (2007/11)	Workers Compensation Insurance Plan Assigned Risk Section	All questions regarding the preparation of this form should be referred to the NCCI Service Center shown on the state instruction pages.
IDENTIFICATION SECTION	Agency Customer ID	Customer's identification number assigned by the agency or brokerage.
APPLICANT INFORMATION
SECTION	Date	Enter date of application.
		Enter the complete legal name of the employer. Provide all applicable D.B.A.'s (Doing
APPLICANT INFORMATION		business as). If more than one named insured, please submit appropriate ERM-14 form(s)
SECTION	Applicant Name	"Confidential Request for Information." Contact NCCI for this form.
		Enter the proposed policy effective date. Such requested effective date shall be the later of the following options:
APPLICANT INFORMATION SECTION	Proposed Effective Date	1. 12:01 A.M. on the date following the receipt by the Plan Administrator of a complete and eligible application, 2. the date of expiration of existing coverage, or 3. a date the application requested.
SUPPLEMENTAL		List the company name, physical address and telephone number where payroll records
INFORMATION	Payroll Office Name and Address	are maintained. A P.O. box address only is not acceptable.
SUPPLEMENTAL		Enter the state which generates the highest payroll and follow all specific instructions for
INFORMATION	State Developing Highest Payroll	this state.
SUPPLEMENTAL	1. Has there been previous	If there was no prior coverage, indicate why by checking the appropriate box for either new
INFORMATION	workers compensation coverage:	business, self insured (independent or group), or insufficient number of employees.

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Section Name	Field Name	Field and/or Section Description
	2. Is there any unpaid workers
	compensation premium due or in	If "YES", explain, including entity name(s) and policy number(s). Details of any
SUPPLEMENTAL	dispute from you or any commonly	outstanding obligations must be furnished in the available space. If more space is
INFORMATION	managed or owned enterprises?	required use the Remarks Section or attach additional sheets of paper.
SUPPLEMENTAL	3. Year Applicant's Business
INFORMATION	Began	List the month, day and year the current owners purchased or started the business.
SUPPLEMENTAL INFORMATION	4. Has there been a name change, consolidation, merger, acquisition, sale, purchase or transfer of assets or ownership change during the past five (5) years?	A signed ERM-14 form "Confidential Request for Information," must accompany the application if a name or ownership change has occurred over the past five years, and has not already been reported. Contact NCCI for this form.
	5. Is applicant related through
SUPPLEMENTAL INFORMATION	common management or ownership to any entity not listed on the ACORD 130 form, whether coverage is required or not?	A signed ERM-14 form "Confidential Request for Information," must accompany the application if applicant is related through common management or ownership to any entity not listed on the ACORD 130 form, whether coverage is required or not. Contact NCCI for this form.
	6. Do you lease workers from a
SUPPLEMENTAL	Professional Employer
INFORMATION	Organization (PEO)?	Refer to the WCIP state instruction sheet for state requirements.
SUPPLEMENTAL	7. Do you lease workers to a client
INFORMATION	company?	Refer to the WCIP state instruction sheet for state requirements.
SUPPLEMENTAL	8. Are you seeking to cover leased
INFORMATION	workers?	Refer to the WCIP state instruction sheet for state requirements.
	9. Do you provide temporary
SUPPLEMENTAL	arrangement services to other
INFORMATION	employers?	If "YES", provide a completed Temporary Labor Contractor Employee form.
SUPPLEMENTAL	10. Do you have a franchise or
INFORMATION	licensing agreement?	If "YES", provide a copy of the agreement.
SUPPLEMENTAL	11. Is coverage requested for a
INFORMATION	sports team?	If "YES", provide the name of the sports team and domiciled state in the space provided.
SUPPLEMENTAL	12. Do trucking classifications
INFORMATION	apply?	If yes, complete questions 13 - 20.

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Section Name	Field Name 13. Do you or your employees	Field and/or Section Description
	regularly operate from a base
	terminal(s) which is/are used to
SUPPLEMENTAL	load, unload, store or transfer	List the complete address for each base terminal which is used by the drivers to load,
INFORMATION	freight?14. Can each driver's state of	unload, and/or transfer freight on a regular basis.
	majority driving time be
SUPPLEMENTAL	established through verifiable	If the state of majority driving time can be established for each driver through verifiable
INFORMATION	records or logs?	logs or records, list the state for each driver in the appropriate section of question 15.
		The drivers listing should include the following for each driver:
		* driver name
	15. Please provide a list of all	* base terminal (if applicable)
	drivers / helpers and their state of	* state of majority driving time (if applicable)
	residence:	* state of residence.
SUPPLEMENTAL	16. What type(s) of goods are
INFORMATION	being hauled?	Describe the type of goods that are being hauled.
SUPPLEMENTAL
INFORMATION	17. Do you own these goods?	Check the applicable box.
SUPPLEMENTAL	18. Is applicant under exclusive
INFORMATION	contract with any retail store(s)?	If "YES", provide a copy of contract(s).
SUPPLEMENTAL	19. Is applicant under exclusive
INFORMATION	contract with any postal service?	If "YES", provide a copy of contract(s).
SUPPLEMENTAL	20. Within what mile radius is
INFORMATION	hauling done?	Provide the number of miles in the space provided.
IDENTIFICATION SECTION INSURANCE COMPANIES	Agency Customer ID	Customer's identification number assigned by the agency or brokerage. An offer of voluntary coverage will affect an applicant's eligibility for Plan coverage;
WHO HAVE OFFERED/	21. Have you received any offers	therefore voluntary offers of coverage must be fully and completely described including
REFUSED INSURANCE	of voluntary coverage?	plan terms.

Section Name	Field Name	Field and/or Section Description
INSURANCE COMPANIES WHO HAVE OFFERED/ REFUSED INSURANCE	22. Indicate the number of insurance companies which have refused the applicant coverage in the last 60 days (or in accordance with state specific guidelines)	Refer to the state instructions for requirements regarding the number of refusals needed before an applicant is eligible for the state's WCIP coverage. Refusal must come from nonaffiliated insurers who are licensed and actively writing workers compensation insurance in the state of application. The employer and/or its representative must retain in file the refusing carrier's name, contact person, address, phone number and date of refusal.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE	Company Name	Provide the company name.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE	Representative Name	Provide the name of the primary contact at the company.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE	Telephone Number	Provide the telephone number where the primary contact may be reached.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE	Date of Refusal	Indicate the date coverage was refused (MM/DD/YYYY).
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE	Comments	Use this space for any comments or remarks.
	23. Is the premium financed
	through a third party premium
PREMIUM PAYMENT	finance company?	If "YES", provide a copy of the agreement.
	24. In applicable jurisdictions on
	qualifying risk, is the loss
	sensitive rating program (LSRP)
PREMIUM PAYMENT	contingency deposit being paid in full at this time?	Check the applicable box.

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