ACORD 130 FL (2015/02) - FLORIDA WORKERS COMPENSATION APPLICATION

ACORD 130 FL (2015/02) - FLORIDA WORKERS COMPENSATION APPLICATION

ACORD 130 FL, Florida Workers Compensation Application, is a Commercial Lines application that is self-contained, as it does not require the

completion of the Applicant Information Section, ACORD 125. As a result, the entire Identification section should be completed.

The countrywide Workers Compensation Application, ACORD 130, cannot be used in Florida. The Florida Workers Compensation Application

provides for Workers Compensation, Employer's Liability, and Voluntary Compensation coverages.

The Policy Information and Rating Information sections follow the Workers' Compensation rules as 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.

Form Page 1

Section Name

Field Name

Description

IDENTIFICATION

Date

Enter date: The date on which the form is completed. (MM/DD/YYYY)

IDENTIFICATION

Producer

Enter text: The full name of the producer / agency.

IDENTIFICATION

Address 1

Enter text: The mailing address line one of the producer / agency.

IDENTIFICATION

Address 2

Enter text: The mailing address line two of the producer / agency.

IDENTIFICATION

City

Enter text: The mailing address city name of the producer / agency.

IDENTIFICATION

State

Enter code: The mailing address state or province code of the producer / agency.

IDENTIFICATION

Zip

Enter code: The mailing address postal code of the producer / agency.

IDENTIFICATION

Phone Number

Enter number: The producer's contact person's phone number. If applicable, include the area

code and extension.

IDENTIFICATION

Fax Number

Enter number: The fax number of the producer / agency.

IDENTIFICATION

License #

Enter identifier: The State License Number of the producer.

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., individual)

within a producer's office (e.g., agency or brokerage).

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.

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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. As

used here, include all subsidiaries and DBAs to be included in coverage, along with their FEIN

(Federal Employer Identification Number).

IDENTIFICATION

Mailing Address

Enter text: The named insured's mailing address line one.

IDENTIFICATION

Mailing Address

Enter text: The named insured's mailing address line two.

IDENTIFICATION

City

Enter text: The named insured's mailing address city name.

IDENTIFICATION

State

Enter code: The named insured's mailing address state or province code.

IDENTIFICATION

Zip

Enter code: The named insured's mailing address postal code.

IDENTIFICATION

Check Box- Additional

Locations

Check the box (if applicable): Indicates the attachment of a list of additional locations.

IDENTIFICATION

Years in Business

Enter number: The number of years the insured has been in business.

IDENTIFICATION

SIC Code

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

Form of Business

Organization - Individual

Check the box (if applicable): Indicates the legal entity code for the named insured is

Individual.

IDENTIFICATION

Partnership

Check the box (if applicable): Indicates the legal entity code for the named insured is

Partnership.

IDENTIFICATION

Corporation

Check the box (if applicable): Indicates the legal entity code for the named insured is

Corporation.

IDENTIFICATION

Subchapter S Corp

Check the box (if applicable): Indicates the legal entity code for the named insured is

Subchapter S Corporation.

IDENTIFICATION

Other

Check the box (if applicable): Indicates the legal entity code for the named insured is other than

those listed on the form.

IDENTIFICATION

Other Description

Enter text: The description of the other legal entity.

IDENTIFICATION

Federal Employer ID

Number

Enter identifier: The tax identifier of the named insured.

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SIC

NCCI I.D. 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.

SIC

Other Rating Bureau I.D.

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

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

Prem Financed

Check the box (if applicable): Indicates the premium has been financed.

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 Record - 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.

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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.

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

Number (#)

Enter number: The producer assigned number of the location.

LOCATIONS

Street, City, County, State,

Zip Code

Enter text: The first address line of the physical location.

LOCATIONS

City

Enter text: The city of the physical location.

LOCATIONS

County

Enter text: The county of the physical location.

LOCATIONS

State

Enter code: The state or province of the physical location.

LOCATIONS

Zip

Enter code: The postal code of the physical location.

LOCATIONS

Number (#)

Enter number: The producer assigned number of the location.

LOCATIONS

Street, City, County, State,

Zip Code

Enter text: The first address line of the physical location.

LOCATIONS

City

Enter text: The city of the physical location.

LOCATIONS

County

Enter text: The county of the physical location.

LOCATIONS

State

Enter code: The state or province of the physical location.

LOCATIONS

Zip

Enter code: The postal code of the physical location.

LOCATIONS

Number (#)

Enter number: The producer assigned number of the location.

LOCATIONS

Street, City, County, State,

Zip Code

Enter text: The first address line of the physical location.

LOCATIONS

City

Enter text: The city of the physical location.

LOCATIONS

County

Enter text: The county of the physical location.

LOCATIONS

State

Enter code: The state or province of the physical location.

LOCATIONS

Zip

Enter code: The postal code of the physical location.

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POLICY INFORMATION

Proposed Eff. Date

Enter date: The effective date of the policy. The date that the terms and conditions of the policy

commence. (MM/DD/YYYY)

POLICY INFORMATION

Proposed Exp. Date

Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)

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

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 (States)

Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law

and/or occupational disease law in states where the insured has operations.

POLICY INFORMATION

Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law

and/or occupational disease law in states where the insured has operations.

POLICY INFORMATION

Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law

and/or occupational disease law in states where the insured has operations.

POLICY INFORMATION

Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law

and/or occupational disease law in states where the insured has operations.

POLICY INFORMATION

Enter code: A state in which Part 1 will apply. Part 1 refers to the workers' compensation law

and/or occupational disease law in states where the insured has operations.

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

Part 2 - Employers Liability $

Ea 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 Ins

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

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.

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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

Deductibles

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

Coinsurance Limit

Enter amount: The Coinsurance Limit amount for benefits due to an employee for an injury

compensable under this policy.

POLICY INFORMATION

Other Coverages - U.S.L &

H.

Check the box (if applicable): Indicates United States Longshoremen's & Harbor Workers'

(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 Compensation

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

Other Check Box

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 and

State Information

Enter text: The additional company or state specific information should be listed in this section.

RATING INFORMATION

Check Here If List Of

Additional Class Codes

Attached

Check the box (if applicable): Indicates the attachment of a list of additional rating classes.

RATING INFORMATION

Location Number

Enter number: The producer assigned number of the location.

RATING INFORMATION

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.

RATING INFORMATION

Company Use

Enter text: This area is to be completed by the insurer.

RATING INFORMATION

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.

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RATING INFORMATION

No. of Employees

Enter number: The number of 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.

RATING INFORMATION

Actual Remuneration Past

12 Months

Enter amount: The actual remuneration of the employee class for the past 12 months.

RATING INFORMATION

Estimated Remuneration for

Next Policy Period

Enter amount: The estimated remuneration of the employee class for the coming policy period.

RATING INFORMATION

Rate

Enter rate: The manual rate for the classification from the appropriate state manual.

RATING INFORMATION

Estimated Annual Premium

Enter amount: The estimated annual manual premium amount for the classification.

RATING INFORMATION

Location Number

Enter number: The producer assigned number of the location.

RATING INFORMATION

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.

RATING INFORMATION

Company Use

Enter text: This area is to be completed by the insurer.

RATING INFORMATION

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.

RATING INFORMATION

No. of Employees

Enter number: The number of 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.

RATING INFORMATION

Actual Remuneration Past

12 Months

Enter amount: The actual remuneration of the employee class for the past 12 months.

RATING INFORMATION

Estimated Remuneration for

Next Policy Period

Enter amount: The estimated remuneration of the employee class for the coming policy period.

RATING INFORMATION

Rate

Enter rate: The manual rate for the classification from the appropriate state manual.

RATING INFORMATION

Estimated Annual Premium

Enter amount: The estimated annual manual premium amount for the classification.

RATING INFORMATION

Location Number

Enter number: The producer assigned number of the location.

RATING INFORMATION

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.

RATING INFORMATION

Company Use

Enter text: This area is to be completed by the insurer.

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RATING INFORMATION

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.

RATING INFORMATION

No. of Employees

Enter number: The number of 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.

RATING INFORMATION

Actual Remuneration Past

12 Months

Enter amount: The actual remuneration of the employee class for the past 12 months.

RATING INFORMATION

Estimated Remuneration for

Next Policy Period

Enter amount: The estimated remuneration of the employee class for the coming policy period.

RATING INFORMATION

Rate

Enter rate: The manual rate for the classification from the appropriate state manual.

RATING INFORMATION

Estimated Annual Premium

Enter amount: The estimated annual manual premium amount for the classification.

RATING INFORMATION

Location Number

Enter number: The producer assigned number of the location.

RATING INFORMATION

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.

RATING INFORMATION

Company Use

Enter text: This area is to be completed by the insurer.

RATING INFORMATION

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.

RATING INFORMATION

No. of Employees

Enter number: The number of 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.

RATING INFORMATION

Actual Remuneration Past

12 Months

Enter amount: The actual remuneration of the employee class for the past 12 months.

RATING INFORMATION

Estimated Remuneration for

Next Policy Period

Enter amount: The estimated remuneration of the employee class for the coming policy period.

RATING INFORMATION

Rate

Enter rate: The manual rate for the classification from the appropriate state manual.

RATING INFORMATION

Estimated Annual Premium

Enter amount: The estimated annual manual premium amount for the classification.

RATING INFORMATION

Location Number

Enter number: The producer assigned number of the location.

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RATING INFORMATION

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.

RATING INFORMATION

Company Use

Enter text: This area is to be completed by the insurer.

RATING INFORMATION

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.

RATING INFORMATION

No. of Employees

Enter number: The number of 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.

RATING INFORMATION

Actual Remuneration Past

12 Months

Enter amount: The actual remuneration of the employee class for the past 12 months.

RATING INFORMATION

Estimated Remuneration for

Next Policy Period

Enter amount: The estimated remuneration of the employee class for the coming policy period.

RATING INFORMATION

Rate

Enter rate: The manual rate for the classification from the appropriate state manual.

RATING INFORMATION

Estimated Annual Premium

Enter amount: The estimated annual manual premium amount for the classification.

RATING INFORMATION

Specify Additional

Coverages / Endorsements

Enter text: Specify any additional coverages and or endorsements that apply.

RATING INFORMATION

Factor

Enter rate: The modification factor for total class premium that is required or applicable.

RATING INFORMATION

Factored Premium

Enter amount: The total premium amount.

RATING INFORMATION

Other Factor Description

Enter text: The description of optional factors, charges or credits that are required or applicable.

RATING INFORMATION

Factor

Enter rate: The modification factor for optional factors, charges or credits that are required or

applicable.

RATING INFORMATION

Factored Premium

Enter amount: The modified premium amount.

RATING INFORMATION

Other Factor Description

Enter text: The description of optional factors, charges or credits that are required or applicable.

RATING INFORMATION

Factor

Enter rate: The modification factor for optional factors, charges or credits that are required or

applicable.

RATING INFORMATION

Factored Premium

Enter amount: The modified premium amount.

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RATING INFORMATION

Experience 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.

RATING INFORMATION

Factored Premium

Enter amount: The modified premium amount.

RATING INFORMATION

Modified Premium - Factor

Enter rate: The modification factor for modified premium that is required or applicable.

RATING INFORMATION

Factored Premium

Enter amount: The modified premium amount.

RATING INFORMATION

Premium Discount - Factor

Enter rate: The modification factor for premium discount. A premium discount may be

applicable due to large premium levels.

RATING INFORMATION

Factored Premium

Enter amount: The modified premium amount.

RATING INFORMATION

Expense Constant -

Factored Premium

Enter amount: The modified premium amount including the flat amount of the expense constant

as applicable per the state rating manual.

RATING INFORMATION

Total Estimated Annual

Premium - Factored

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.

RATING INFORMATION

Minimum Premium

Enter amount: The minimum premium amount required by company rules for this state.

RATING INFORMATION

Deposit Premium

Enter amount: The amount of deposit required by rules for this state.

Form Page 2

Section Name

Field Name

Description

INDIVIDUALS INCLUDED /

EXCLUDED

Name

Enter text: The full name of the partner or executive officer being included or excluded by the

policy.

INDIVIDUALS INCLUDED /

EXCLUDED

Date of Birth

Enter date: The individual's birth date.

INDIVIDUALS INCLUDED /

EXCLUDED

Social Security #

Enter number: The individual's social security number.

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.

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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

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

Name

Enter text: The full name of the partner or executive officer being included or excluded by the

policy.

INDIVIDUALS INCLUDED /

EXCLUDED

Date of Birth

Enter date: The individual's birth date.

INDIVIDUALS INCLUDED /

EXCLUDED

Social Security #

Enter number: The individual's social security number.

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

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

Name

Enter text: The full name of the partner or executive officer being included or excluded by the

policy.

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Page 12 of 23

INDIVIDUALS INCLUDED /

EXCLUDED

Date of Birth

Enter date: The individual's birth date.

INDIVIDUALS INCLUDED /

EXCLUDED

Social Security #

Enter number: The individual's social security number.

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

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).

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Loss Run Attached

Check the box (if applicable): Indicates a loss run is attached to this application.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Year

Enter year: The year the prior coverage policy term became effective.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Carrier

Enter text: The name of the previous insurer.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Policy Number

Enter identifier: The policy number of the previous coverage.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Actual Audited Premium

Enter amount: The actual / audited premium charged for the specified line of business.

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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. As used here, this is the

total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Reserve

Enter amount: The reserve amount the previous carrier is holding open for this claim. As used

here, this is the total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Year

Enter year: The year the prior coverage policy term became effective.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Carrier

Enter text: The name of the previous insurer.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Policy Number

Enter identifier: The policy number of the previous coverage.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Actual Audited Premium

Enter amount: The actual / audited premium charged 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. As used here, this is the

total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Reserve

Enter amount: The reserve amount the previous carrier is holding open for this claim. As used

here, this is the total for all claims on the policy.

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PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Year

Enter year: The year the prior coverage policy term became effective.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Carrier

Enter text: The name of the previous insurer.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Policy Number

Enter identifier: The policy number of the previous coverage.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Actual Audited Premium

Enter amount: The actual / audited premium charged 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. As used here, this is the

total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Reserve

Enter amount: The reserve amount the previous carrier is holding open for this claim. As used

here, this is the total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Year

Enter year: The year the prior coverage policy term became effective.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Carrier

Enter text: The name of the previous insurer.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Policy Number

Enter identifier: The policy number of the previous coverage.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Actual Audited Premium

Enter amount: The actual / audited premium charged for the specified line of business.

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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. As used here, this is the

total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Reserve

Enter amount: The reserve amount the previous carrier is holding open for this claim. As used

here, this is the total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Year

Enter year: The year the prior coverage policy term became effective.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Carrier

Enter text: The name of the previous insurer.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Policy Number

Enter identifier: The policy number of the previous coverage.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Actual Audited Premium

Enter amount: The actual / audited premium charged 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. As used here, this is the

total for all claims on the policy.

PRIOR CARRIER

INFORMATION / LOSS

HISTORY

Reserve

Enter amount: The reserve amount the previous carrier is holding open for this claim. As used

here, this is the total for all claims on the policy.

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NATURE OF BUSINESS /

DESCRIPTION OF

OPERATIONS

Professional Employer

Organization (PEO) /

Employee Leasing Company

Check the box (if applicable): Indicate if professional employer organization (PEO)/employee

leasing company.

NATURE OF BUSINESS /

DESCRIPTION OF

OPERATIONS

Temporary Employment

Service

Check the box (if applicable): Indicate if temporary Employment service.

NATURE OF BUSINESS /

DESCRIPTION OF

OPERATIONS

Empty Field Box

Enter text: The description of the operations of this risk or insured.

EMPLOYEES

Name

Enter text: The full name of the individual employee.

EMPLOYEES

Class Code

Enter text: The class code of the individual employee.

EMPLOYEES

Social Security #

Enter number: The individual's social security number.

EMPLOYEES

Name

Enter text: The full name of the individual employee.

EMPLOYEES

Class Code

Enter text: The class code of the individual employee.

EMPLOYEES

Social Security #

Enter number: The individual's social security number.

EMPLOYEES

Name

Enter text: The full name of the individual employee.

EMPLOYEES

Class Code

Enter text: The class code of the individual employee.

EMPLOYEES

Social Security #

Enter number: The individual's social security number.

EMPLOYEES

Name

Enter text: The full name of the individual employee.

EMPLOYEES

Class Code

Enter text: The class code of the individual employee.

EMPLOYEES

Social Security #

Enter number: The individual's social security number.

EMPLOYEES

Name

Enter text: The full name of the individual employee.

EMPLOYEES

Class Code

Enter text: The class code of the individual employee.

EMPLOYEES

Social Security #

Enter number: The individual's social security number.

EMPLOYEES

Name

Enter text: The full name of the individual employee.

EMPLOYEES

Class Code

Enter text: The class code of the individual employee.

EMPLOYEES

Social Security #

Enter number: The individual's social security number.

GENERAL INFORMATION

Does applicant own, operate

or lease aircraft /

watercraft?

Check the box (if applicable): Indicates a Yes response to the question, Does applicant own,

operate or lease aircraft or watercraft?.

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Page 17 of 23

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Does applicant own,

operate or lease aircraft or watercraft?.

GENERAL INFORMATION

Do / have past, present or

discontinued operations

involved storing, treating,

discharging, applying,

disposing, or transporting

of hazardous material?

Check the box (if applicable): Indicates a Yes response to the question, Do / have past,

present or discontinued operations involve(d) storing, treating, discharging, applying, disposing,

or transporting of hazardous material?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Do / have past,

present or discontinued operations involve(d) storing, treating, discharging, applying, disposing,

or transporting of hazardous material?.

GENERAL INFORMATION

Any work performed

underground or above 15

feet?

Check the box (if applicable): Indicates a Yes response to the question, Any work performed

underground or above 15 feet?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any work performed

underground or above 15 feet?.

GENERAL INFORMATION

Any work performed on

barges, vessels, docks,

bridge over water?

Check the box (if applicable): Indicates a Yes response to the question, Any work performed

on barges, vessels, docks, bridge over water?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any work performed

on barges, vessels, docks, bridge over water?.

GENERAL INFORMATION

Is applicant engaged in any

other type of business?

Check the box (if applicable): Indicates a Yes response to the question, Is applicant engaged

in any other type of business?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Is applicant engaged

in any other type of business?.

GENERAL INFORMATION

Are sub-contractors and/or

independent contractors

used?

Check the box (if applicable): Indicates a Yes response to the question, Are subcontractors

used?. As used here, include independent contractors.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Are subcontractors

used?. As used here, include independent contractors.

GENERAL INFORMATION

Any work sublet without

certificates of ins.?

Check the box (if applicable): Indicates a Yes response to the question, Any work sublet

without certificates of insurance?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any work sublet

without certificates of insurance?.

GENERAL INFORMATION

Is a formal safety program

in operation?

Check the box (if applicable): Indicates a Yes response to the question, Is a written safety

program in operation?.

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Page 18 of 23

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Is a written safety

program in operation?.

GENERAL INFORMATION

Any group transportation

provided?

Check the box (if applicable): Indicates a Yes response to the question, Any group

transportation provided?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any group

transportation provided?.

GENERAL INFORMATION

Any employees under 16 or

over 60 years of age?

Check the box (if applicable): Indicates a Yes response to the question, Any employees under

16 or over 60 years of age?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any employees under

16 or over 60 years of age?.

GENERAL INFORMATION

Any part time or seasonal

employees?

Check the box (if applicable): Indicates a Yes response to the question, Any seasonal

employees?. As used here, include part-time employees.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any seasonal

employees?. As used here, include part-time employees.

GENERAL INFORMATION

Is there any volunteer or

donated labor?

Check the box (if applicable): Indicates a Yes response to the question, Is there any volunteer

or donated labor?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Is there any volunteer

or donated labor?.

GENERAL INFORMATION

Any employees with

physical handicaps?

Check the box (if applicable): Indicates a Yes response to the question, Any employees with

physical handicaps?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any employees with

physical handicaps?.

GENERAL INFORMATION

Do employees travel out of

state?

Check the box (if applicable): Indicates a Yes response to the question, Do employees travel

out of state?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Do employees travel

out of state?.

GENERAL INFORMATION

Are athletic teams

sponsored?

Check the box (if applicable): Indicates a Yes response to the question, Are athletic teams

sponsored?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Are athletic teams

sponsored?.

GENERAL INFORMATION

Are physicals required after

offers of employment are

made?

Check the box (if applicable): Indicates a Yes response to the question, Are physicals

required after offers of employment are made?.

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Page 19 of 23

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Are physicals required

after offers of employment are made?.

GENERAL INFORMATION

Any other insurance with

this insurer?

Check the box (if applicable): Indicates a Yes response to the question, Any other insurance

with this company?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any other insurance

with this company?.

GENERAL INFORMATION

Any prior coverage declined

/ cancelled / non-renewed

last 3 years?

Check the box (if applicable): Indicates a Yes response to the question, Any policy or

coverage declined, cancelled or non-renewed in the last three (3) years?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Any policy or coverage

declined, cancelled or non-renewed in the last three (3) years?.

GENERAL INFORMATION

Are employee health plans

provided?

Check the box (if applicable): Indicates a Yes response to the question, Are Employee Health

Plans provided?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Are Employee Health

Plans provided?.

GENERAL INFORMATION

Is there a labor interchange

with any other business /

subsidiary?

Check the box (if applicable): Indicates a Yes response to the question, Is there a labor

interchange with any other business or subsidiary?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Is there a labor

interchange with any other business or subsidiary?.

GENERAL INFORMATION

Do you lease employees to

or from other employers?

Check the box (if applicable): Indicates a Yes response to the question, Do you lease

employees to or from other employers?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Do you lease

employees to or from other employers?.

GENERAL INFORMATION

Do any employees

predominantly work at

home?

Check the box (if applicable): Indicates a Yes response to the question, Do any employees

predominantly work from home?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Do any employees

predominantly work from home?.

GENERAL INFORMATION

What are your estimated

annual revenues?

Enter amount: The estimated annual revenues.

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Page 20 of 23

GENERAL INFORMATION

Is there any current or

anticipated debt for unpaid

premiums owed to any

previous workers'

compensation provider?

Check the box (if applicable): Indicates a Yes response to the question, Are you in debt to any

insurance company for any unpaid premium for worker's compensation?. As used here,

include any anticipated debt for unpaid premiums.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Are you in debt to any

insurance company for any unpaid premium for worker's compensation?. As used here,

include any anticipated debt for unpaid premiums.

GENERAL INFORMATION

Inspection - 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.

GENERAL 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.

GENERAL INFORMATION

Accounting Records -

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.

GENERAL 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.

GENERAL INFORMATION

Claims Information - Phone

Enter number: The telephone number of the person the insurer is to contact regarding any

potential claims inquiries.

GENERAL INFORMATION

Claims Information - Name

Enter text: The full name of the person the insurer is to contact regarding any potential claims

inquiries.

GENERAL INFORMATION

Remarks

Enter text: The remarks associated with the Workers Compensation line of business. ACORD

101, Additional Remarks Schedule, may be attached if more space is required.

Form Page 3

Section Name

Field Name

Description

GENERAL INFORMATION

Former Names and Owners

Enter text: For the last five years, list the current business name and any former names or

predecessor companies to be covered by the policy. Include the FEIN for each company. For

each covered company, list any current owner who has more than 5% ownership interest.

GENERAL INFORMATION

Check the box (if applicable): Indicates a Yes response to the question, Does this business or

any of the owners of this business, either individually or in combination with other owners of this

business, own more than 50% of any other business, which operated at any time during the five

years prior to this application?

GENERAL INFORMATION

Check Box- No

Check the box (if applicable): Indicates a No response to the question, Does this business or

any of the owners of this business, either individually or in combination with other owners of this

business, own more than 50% of any other business, which operated at any time during the five

years prior to this application?

ACORD 130 FL (2015/02) rev. 04-03-2015

Page 21 of 23

GENERAL INFORMATION

Does this business own a

majority interest in another

entity, which in turn owns a

majority interest in any

entity that operated at any

time in the five years prior

to this application? - Check

Box - Yes

Check the box (if applicable): Indicates a Yes response to the question, Does this business

own a majority interest in another entity, which in turn owns a majority interest in any entity that

operated at any time in the five years prior to this application?.

GENERAL INFORMATION

Check Box - No

Check the box (if applicable): Indicates a No response to the question, Does this business

own a majority interest in another entity, which in turn owns a majority interest in any entity that

operated at any time in the five years prior to this application?.

SIGNATURE SECTION

Identify by name, address,

and FEIN each business

which is related by common

ownership to the applicant

business.

Enter text: An explanation of name, address, and FEIN for each business which is related by

common ownership to the applicant business.

SIGNATURE SECTION

Set forth the dates each

business was in operation,

the insurance company that

provided Workers'

Compensation insurance,

the policy number and the

Experience Modification

Factor applied to each such

policy.

Enter text: An explanation of the dates each business was in operation, the insurance company

that provided workers' compensation insurance, the policy number and the experience

modification factor applied to each such policy

SIGNATURE SECTION

If the policy was written

without an Experience

Modification Factor, please

state.

Enter text: An explanation that a policy was written without an experience modification factor.

SIGNATURE SECTION

Owner / Officer Signature

Sign here: The signature of the owner or authorized officer.

SIGNATURE SECTION

Date

Enter date: the date the owner or authorized officer signed the form.

SIGNATURE SECTION

Print Name

Enter text: The printed name of the authorized signer.

SIGNATURE SECTION

Notary Public Signature

Sign here: Accommodates the signature of the notary public.

SIGNATURE SECTION

Date

Enter date: The date the notary public signed the form.

SIGNATURE SECTION

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 SECTION

Date

Enter date: The date the producer signed the form.

ACORD 130 FL (2015/02) rev. 04-03-2015

Page 22 of 23

SIGNATURE SECTION

Notary Public Signature

Sign here: Accommodates the signature of the notary public.

SIGNATURE SECTION

Date

Enter date: The date the notary public signed the form.

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