ACORD 130 (2013/09) - WORKERS COMPENSATION APPLICATION
ACORD 130 (2013/09) - WORKERS COMPENSATION APPLICATION
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.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION
Date (MM/DD/YYYY)
Enter date: The date on which the form is completed.
IDENTIFICATION
Agency Name and Address
Enter text: The full name of the producer / agency.
IDENTIFICATION
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION
Enter code: The mailing address postal code of the producer / agency.
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. If applicable, include the area
code and extension. 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 / agency.
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 (2013/09) rev. 07-31-2013 P age 1 of 34
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. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION
Underwriter
Enter text: The company underwriter (or other company staff person) that this form should be
directed to.
IDENTIFICATION
Applicant Name
Enter text: The named insured(s) as it/they will appear 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). This is the code which represents the nature of the employer's business which is
contained in the Standard Industrial Classification Manual published by the Federal Office of
Management and Budget.
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.
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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.
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
Other Description
Enter text: The description of the legal entity if not listed on the form.
IDENTIFICATION
Unincorporated Association
Check the box (if applicable): Indicates the legal entity code for the named insured is an
Unincorporated Association.
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 date on which the terms and conditions of the binder commenced. This date
normally coincides with the effective date of the policy or of an endorsement to the policy.
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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.
STATUS OF SUBMISSION
Issue Policy
Check the box (if applicable): Indicates the response expected from the company is an 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
INFORMATION
Other
Check the box (if applicable): Indicates the policy will be paid in a frequency other than those
listed.
BILLING / AUDIT
INFORMATION
Other Description
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly,
etc.).
BILLING / AUDIT
INFORMATION
% Down
Enter percentage: The percentage of the total estimated annual premium that has been (or will
be) received as a down payment for bound policies.
BILLING / AUDIT
INFORMATION
Audit - At Expiration
Check the box (if applicable): Indicates audits should be performed for this policy at expiration.
BILLING / AUDIT
INFORMATION
Semi-Annual
Check the box (if applicable): Indicates audits should be performed for this policy semi-annually.
BILLING / AUDIT
INFORMATION
Quarterly
Check the box (if applicable): Indicates audits should be performed for this policy quarterly.
BILLING / AUDIT
INFORMATION
Monthly
Check the box (if applicable): Indicates audits should be performed for this policy monthly.
BILLING / AUDIT
INFORMATION
Other
Check the box (if applicable): Indicates audits should be performed for this policy at a frequency
other than those listed.
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BILLING / AUDIT
INFORMATION
Other Description
Enter code: The audit term for policies that are subject to periodic audit. If the audit period is
known, enter the code; A - annual, S - semi-annual, Q - Quarterly, M - Monthly, O - Other.
LOCATIONS
LOC #
Enter number: The producer assigned number of the location.
LOCATIONS
Highest Floor
Enter number: The highest floor of the physical location.
LOCATIONS
Street, City, County, State,
Zip Code
Enter text: The first address line of the physical location.
LOCATIONS
Enter text: The second address line of the physical location.
LOCATIONS
Enter text: The city of the physical location.
LOCATIONS
Enter text: The county of the location.
LOCATIONS
Enter code: The state or province of the physical location.
LOCATIONS
Enter code: The postal code of the physical location.
LOCATIONS
LOC #
Enter number: The producer assigned number of the location.
LOCATIONS
Highest Floor
Enter number: The highest floor of the physical location.
LOCATIONS
Street, City, County, State,
Zip Code
Enter text: The first address line of the physical location.
LOCATIONS
Enter text: The second address line of the physical location.
LOCATIONS
Enter text: The city of the physical location.
LOCATIONS
Enter text: The county of the location.
LOCATIONS
Enter code: The state or province of the physical location.
LOCATIONS
Enter code: The postal code of the physical location.
LOCATIONS
LOC #
Enter number: The producer assigned number of the location.
LOCATIONS
Highest Floor
Enter number: The highest floor of the physical location.
LOCATIONS
Street, City, County, State,
Zip Code
Enter text: The first address line of the physical location.
LOCATIONS
Enter text: The second address line of the physical location.
LOCATIONS
Enter text: The city of the physical location.
LOCATIONS
Enter text: The county of the location.
LOCATIONS
Enter code: The state or province of the physical location.
ACORD 130 (2013/09)
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LOCATIONS
Enter code: The postal code of the physical location.
POLICY INFORMATION
Proposed Policy Eff Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. 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.
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.
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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
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 (2013/09)
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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.
POLICY INFORMATION
Voluntary Comp
Check the box (if applicable): Indicates Voluntary Compensation coverage is requested.
Exposures for this optional coverages as well as additional coverages should be described in
the Specify Additional Coverages/Endorsements section.
POLICY INFORMATION
Foreign Cov
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 Additional
Coverages/Endorsements section.
ACORD 130 (2013/09)
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POLICY INFORMATION
Managed Care Option
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 Specify Additional
Coverages/Endorsements section.
POLICY INFORMATION
Other
Check the box (if applicable): Indicates other coverages than those listed are being requested.
POLICY INFORMATION
Other Description
Enter text: The description of the coverage being requested.
POLICY INFORMATION
Other
Check the box (if applicable): Indicates other coverages than those listed are being requested.
POLICY INFORMATION
Other Description
Enter text: The description of the coverage being requested.
POLICY INFORMATION
Dividend Plan or Safety
Group
Enter text: The specific plan or safety group of which the insured is a member. This field is
related to the participating plan. Check with your company on the availability of plans.
POLICY INFORMATION
Additional Company
Information
Enter text: The additional company or state specific information should be listed in this section.
POLICY INFORMATION
Specify Additional
Coverages/Endorsements
Enter text: The description of exposures for the optional coverages selected in the Other
Coverages section. Any additional coverages should also be described.
TOTAL ESTIMATED
ANNUAL PREMIUM - ALL
STATE
Total Estimated Annual
Premium All States
Enter amount: The amount resulting from applying all modifications, discounts, taxes and 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.
CONTACT INFORMATION
Inspection (Name)
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 and number.
CONTACT INFORMATION
Inspection (Office Phone)
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, this is
the office phone number.
CONTACT INFORMATION
Inspection (Mobile Phone)
Enter number: The cell phone number of the person to contact to arrange for a premises
inspection. This should be an individual under the insured's employment.
CONTACT INFORMATION
Inspection (E-Mail Address)
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 the insurance
agent's name and number.
CONTACT INFORMATION
Accounting Records (Name)
Enter text: The name of the person to contact for accounting information. This should be an
individual under the insured's employment, not the insurance agent.
ACORD 130 (2013/09)
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CONTACT INFORMATION
Accounting Records (Office
Phone)
Enter number: The telephone number of the person to contact for accounting information. This
should be an individual under the insured's employment, not the insurance agent's name and
number. As used here, this is the office phone number.
CONTACT INFORMATION
Accounting Records (Mobile
Phone)
Enter number: The cell phone number of the person to contact for accounting information.
CONTACT INFORMATION
Accounting Records (E-Mail
Address)
Enter text: The e-mail address (if applicable) of the person to contact for accounting information.
This should be an individual under the insured's employment, not the insurance agent's name
and number.
CONTACT INFORMATION
Claims Information (Name)
Enter text: The full name of the person the insurer is to contact regarding any potential claims
inquiries.
CONTACT INFORMATION
Claims Information (Office
Phone)
Enter number: The telephone number of the person the insurer is to contact regarding any
potential claims inquiries. As used here, this is the office phone number.
CONTACT INFORMATION
Claims Information (Mobile
Phone)
Enter number: The cell phone number of the person the insurer is to contact regarding any
potential claims inquiries.
CONTACT INFORMATION
Claims Information (E-Mail
Address)
Enter text: The e-mail address (if applicable) of the person the insurer is to contact 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 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 (2013/09)
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INDIVIDUALS INCLUDED /
EXCLUDED
Remuneration/Payroll
Enter amount: The estimated annual remuneration for individual listed. 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 individual listed. 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.
ACORD 130 (2013/09)
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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 individual listed. 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.
ACORD 130 (2013/09)
Page 12 of 34
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 individual listed. 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).
Form Page 2
Section Name
Field Name
Description
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
ACORD 130 (2013/09)
Page 13 of 34
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry code
assigned to the particular type of business (if known).
ACORD 130 (2013/09)
Page 14 of 34
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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
ACORD 130 (2013/09)
Page 15 of 34
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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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.
ACORD 130 (2013/09)
Page 16 of 34
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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 (2013/09)
Page 17 of 34
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
ACORD 130 (2013/09)
Page 18 of 34
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry code
assigned to the particular type of business (if known).
ACORD 130 (2013/09)
Page 19 of 34
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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
ACORD 130 (2013/09)
Page 20 of 34
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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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.
ACORD 130 (2013/09)
Page 21 of 34
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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 (2013/09)
Page 22 of 34
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
ACORD 130 (2013/09)
Page 23 of 34
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry 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.
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.
STATE RATING
WORKSHEET
No. of Employees, Full Time
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate.
STATE RATING
WORKSHEET
No. of Employees, Part Time
Enter number: The number of part time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year. Underwriters use
this number to determine if the payroll estimates appear adequate
STATE RATING
WORKSHEET
SIC
Enter code: The Standard Industry Class code assigned to the particular type of business (if
known).
STATE RATING
WORKSHEET
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry code
assigned to the particular type of business (if known).
ACORD 130 (2013/09)
Page 24 of 34
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.
PREMIUM
Total - Factored Premium
Enter amount: The total premium amount.
PREMIUM
Increased Limits - Factor
Enter rate: The modification factor if limits other than the standard limits for Part 2 Employers
Liability are requested.
PREMIUM
increased Limits - Factored
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.
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
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.
ACORD 130 (2013/09)
Page 25 of 34
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.
PREMIUM
Premium Discount - Factor
Enter rate: The modification factor for premium discount. A premium discount may be
applicable due to large premium levels.
PREMIUM
Premium Discount -
Factored Premium
Enter amount: The modified premium amount.
PREMIUM
Expense Constant
Enter amount: The modified premium amount including the flat amount of the expense constant
as applicable per the state rating manual.
PREMIUM
Taxes/Assessments *
Enter amount: The modified premium amount including state taxes and assessments
applicable.
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.
ACORD 130 (2013/09)
Page 26 of 34
PREMIUM
Total Estimated Annual
Premium
Enter amount: The amount resulting from applying all modifications, discounts, taxes and 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. ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., 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
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 number: 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.
ACORD 130 (2013/09)
Page 27 of 34
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 number: 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.
ACORD 130 (2013/09)
Page 28 of 34
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 number: 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 number: 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.
ACORD 130 (2013/09)
Page 29 of 34
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 number: 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.
NATURE OF BUSINESS /
DESCRIPTION OF
OPERATIONS
Nature of Business /
Description of Operations
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, because they do not provide adequate detail.
For example, a manufacturer of pulley wheels used in sewing machines should be described as
such and not as Metal Goods Mfg. N.O.C.
ACORD 130 (2013/09)
Page 30 of 34
GENERAL INFORMATION
1. Does applicant own,
operate or lease aircraft /
watercraft?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant own, operate or lease aircraft or watercraft?.
GENERAL INFORMATION
Remarks
Enter text: A statement explaining if applicant owns, operates or leases aircraft / watercraft.
GENERAL INFORMATION
2. Do/Have past, present or
discontinued operations
involve(d) storing, treating,
discharging, applying,
disposing, or transporting
of hazardous material?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do/have past, present or discontinued operations involve(d) storing, treating, discharging,
applying, disposing, or transporting of hazardous material?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any past, present or discontinued operations involving storing,
treating, discharging, applying, disposing, or transporting of hazardous material.
GENERAL INFORMATION
3.Any work performed
underground or above 15
feet?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any work performed underground or above 15 feet?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any work performed underground or above 15 ft.
GENERAL INFORMATION
4. Any work performed on
barges, vessels, docks or
bridge over water?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is work performed on barges, vessels, docks, bridge over water?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any work performed on barges, vessels, docks or bridges over
water.
GENERAL INFORMATION
5. Is applicant engaged in
any other type of business?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is applicant engaged in any other type of business?.
GENERAL INFORMATION
Remarks
Enter text: A statement explaining if applicant engaged in any other type of business.
GENERAL INFORMATION
6. Are subcontractors used?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are subcontractors used?.
GENERAL INFORMATION
Remarks
Enter text: A statement explaining if subcontractors are used.
GENERAL INFORMATION
7. Any work sublet without
certificates of insurance?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any work sublet without certificates of insurance?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any work sublet without certificates of insurance.
GENERAL INFORMATION
8. Is a written safety
program in operation?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is a written safety program in operation?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any written safety program in operation.
ACORD 130 (2013/09)
Page 31 of 34
GENERAL INFORMATION
9. Any group transportation
provided?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any group transportation provided?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any group transportation provided.
GENERAL INFORMATION
10. Any employees under 16
or over 60 years of age?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any employees under 16 or over 60 years of age?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any employees under 16 or over 60 years of age.
GENERAL INFORMATION
11. Any seasonal
employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any seasonal employees?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any seasonal employees.
GENERAL INFORMATION
12. Is there any volunteer or
donated labor?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there any volunteer or donated labor?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any volunteer or donated labor.
GENERAL INFORMATION
13. Any employees with
physical handicaps?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any employees with physical handicaps?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any employees with physical handicaps.
GENERAL INFORMATION
14. Do employees travel out
of state?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do employees travel out of state?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any employees who travel out of state.
GENERAL INFORMATION
15. Are athletic teams
sponsored?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are athletic teams sponsored?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any athletic teams that are sponsored.
GENERAL INFORMATION
(continued)
16. Are physicals required
after offers of employment
are made?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are physicals required after offers of employment are made?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: A statement explaining if physicals are required after offers of employment are made.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ACORD 130 (2013/09)
Page 32 of 34
GENERAL INFORMATION
(continued)
17. Any other insurance with
this insurer?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any other insurance with this company?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any other insurance with this insurer.
GENERAL INFORMATION
(continued)
18. Any prior coverage
declined/cancelled/non-renewed
in the last three (3) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any policy or coverage declined, cancelled or non-renewed during the mandated number of
years (Not applicable in Missouri)?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any prior coverage declined/cancelled/non-renewed in the last
three (3) years.
GENERAL INFORMATION
(continued)
19. Are employee health
plans provided?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there an Employee Health Plan provided?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any employee health plans provided.
GENERAL INFORMATION
(continued)
20. Do any employees
perform work for other
businesses or subsidiaries?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do any employees perform work for other businesses or subsidiaries?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any employees who perform work for other businesses or
subsidiaries.
GENERAL INFORMATION
(continued)
21. Do you lease employees
to or from other employers
?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you lease employees to or from other employers?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any employees leased to or from other employers.
GENERAL INFORMATION
(continued)
22. Do any employees
predominantly work at
home?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do employees predominantly work from home?.
GENERAL INFORMATION
(continued)
If YES, # of employees:
Enter number: The number of employees that predominantly work from home.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any employees predominantly working at home.
GENERAL INFORMATION
(continued)
23. Any tax liens or
bankruptcy within the last
five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any tax liens or bankruptcy within the past mandated number of years?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any tax liens or bankruptcy within the last five (5) years.
ACORD 130 (2013/09)
Page 33 of 34
GENERAL INFORMATION
(continued)
24. Any undisputed and
unpaid workers
compensation premium due
from you or any company
managed or owned
enterprises?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any undisputed and unpaid workers compensation premium due from you or any commonly
managed or owned enterprises?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of any undisputed and unpaid workers compensation premium due
from you or any company managed or owned enterprises.
SIGNATURE
Notice of Information
Practices (Privacy)
checkbox
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s
are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD
38 contains CA and MA state specific language.
SIGNATURE
Applicant's Initials
Initial here: The named insured's initials.
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.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 130 (2013/09)
Page 34 of 34