ACORD 133 (2015/05) - Workers Compensation Insurance Plan Assigned Risk Section

ACORD 133 (2015/05) - Workers Compensation Insurance Plan Assigned Risk Section
ACORD 133, Workers Compensation Insurance Plan Assigned Risk Section, is designed to be used in conjunction with the ACORD Workers
Compensation Application (ACORD 130). These two forms collect the data necessary for submitting assigned risk business.
Please answer all questions thoroughly. Any omission may result in delay or denial of coverage. Where space restricts a complete answer, attach
answer on a separate sheet of paper. These applications do not provide coverage.
Refer to the National Council on Compensation Insurance Inc. (NCCI) WCIP State Instruction pages for state specific instructions on completing
the ACORD 133 and ACORD 130 for WCIP business.
All questions regarding the preparation of this form should be referred to the NCCI Service Center shown on the state instruction pages.
Form Page 1
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).
APPLICANT INFORMATION
SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
APPLICANT INFORMATION
SECTION
Applicant Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page. As
used here, enter the complete legal name of the employer. Provide all applicable D.B.A.'s
(Doing business as). If more than one named insured, please submit appropriate ERM-14
form(s) Confidential Request for Information. Contact NCCI for this form.
APPLICANT INFORMATION
SECTION
Proposed Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY) As used here, enter the proposed policy effective date. Such
requested effective date shall be the later of the following options:
1. 12:01 A.M. on the date following the receipt by the Plan Administrator of a complete and
eligible application,
2. the date of expiration of existing coverage, or
3. a date the application requested.
APPLICANT INFORMATION
SECTION
Payroll Office Name and
Address
Enter text: The full name of the location. As used here, list the company name, physical address
and telephone number where payroll records are maintained. A P.O. box address only is not
acceptable.
APPLICANT INFORMATION
SECTION
Enter text: The first address line of the physical location.
APPLICANT INFORMATION
SECTION
Enter text: The second address line of the physical location.
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Page 1 of 13
APPLICANT INFORMATION
SECTION
Enter text: The city of the physical location.
APPLICANT INFORMATION
SECTION
Enter code: The state or province of the physical location.
APPLICANT INFORMATION
SECTION
Enter code: The postal code of the physical location.
APPLICANT INFORMATION
SECTION
Enter number: The primary phone number of the location.
SUPPLEMENTAL
INFORMATION
State Developing Highest
Payroll
Enter code: The state which generates the highest payroll. Follow all specific instructions for
this state.
SUPPLEMENTAL
INFORMATION
Has there been previous
workers compensation
coverage: In this state? Yes
Check the box (if applicable): Indicates a Yes response to the question, Has there been
previous workers compensation coverage in this state?. As used here, If there was no prior
coverage, indicate why by checking the appropriate box for either new business, self insured
(independent or group), or insufficient number of employees.
SUPPLEMENTAL
INFORMATION
Has there been previous
workers compensation
coverage: In this state? No
Check the box (if applicable): Indicates a No response to the question, Has there been
previous workers compensation coverage in this state?.
SUPPLEMENTAL
INFORMATION
Has there been previous
workers compensation
coverage: In any other
state? Yes
Check the box (if applicable): Indicates a Yes response to the question, Has there been
previous workers compensation coverage in any other state?.
SUPPLEMENTAL
INFORMATION
Has there been previous
workers compensation
coverage: In any other
state? No
Check the box (if applicable): Indicates a No response to the question, Has there been
previous workers compensation coverage in any other state?.
SUPPLEMENTAL
INFORMATION
If No to Both - New
Business
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
SUPPLEMENTAL
INFORMATION
If No to Both - Self
Insured-Indep
Check the box (if applicable): Indicates if the insured is independently self-insured.
SUPPLEMENTAL
INFORMATION
If No to Both - Self
Insured-Group
Check the box (if applicable): Indicates if the insured is self-insured as part of a group.
SUPPLEMENTAL
INFORMATION
If No to Both - # Employees
Check the box (if applicable): Indicates there was no previous coverage due to the number of
employees.
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SUPPLEMENTAL
INFORMATION
Is there any unpaid workers
compensation premium due
or in dispute from you or
any commonly managed or
owned enterprises? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there any unpaid
workers compensation premium due or in dispute from you or any commonly managed or
owned enterprise?. As used here, if YES, explain, including entity name(s) and policy
number(s). Details of any outstanding obligations must be furnished in the available space. If
more space is required use the Remarks Section or attach additional sheets of paper.
SUPPLEMENTAL
INFORMATION
Is there any unpaid workers
compensation premium due
or in dispute from you or
any commonly managed or
owned enterprises? No
Check the box (if applicable): Indicates a No response to the question, Is there any unpaid
workers compensation premium due or in dispute from you or any commonly managed or
owned enterprise?.
SUPPLEMENTAL
INFORMATION
Explain
Enter text: An explanation of a response to a general information or underwriting question.
Normally, Yes responses require an explanation.
SUPPLEMENTAL
INFORMATION
Year Applicant's Business
Began
Enter year: The year the business was started.
SUPPLEMENTAL
INFORMATION
Has there been a name
change, consolidation,
merger or ownership
change during the past five
years? Yes
Check the box (if applicable): Indicates a Yes response to the question, Has there been a
name change, consolidation, merger, acquisition, sale, purchase or transfer of assets or
ownership change during the past mandated number of years?. As used here, a signed
ERM-14 form Confidential Request for Information, must accompany the application if a name
or ownership change has occurred over the past five years, and has not already been reported.
Contact NCCI for this form.
SUPPLEMENTAL
INFORMATION
Has there been a name
change, consolidation,
merger or ownership
change during the past five
years? No
Check the box (if applicable): Indicates a No response to the question, Has there been a
name change, consolidation, merger, acquisition, sale, purchase or transfer of assets or
ownership change during the past mandated number of years?.
SUPPLEMENTAL
INFORMATION
Is applicant related through
common management or
ownership to any entity not
listed here, whether
coverage is required or not?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Is the applicant
related through common management or ownership to any entity not listed here whether
coverage is required or not?. As used here, a signed ERM-14 form Confidential Request for
Information, must accompany the application if applicant is related through common
management or ownership to any entity not listed on the ACORD 130 form, whether coverage is
required or not. Contact NCCI for this form.
SUPPLEMENTAL
INFORMATION
Is applicant related through
common management or
ownership to any entity not
listed here, whether
coverage is required or not?
No
Check the box (if applicable): Indicates a No response to the question, Is the applicant related
through common management or ownership to any entity not listed here whether coverage is
required or not?.
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SUPPLEMENTAL
INFORMATION
Do you lease workers from a
professional employers
organization? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you lease workers
from a professional employer organization (PEO)?. As used here, refer to the WCIP state
instruction sheet for state requirements.
SUPPLEMENTAL
INFORMATION
Do you lease workers from a
professional employers
organization? No
Check the box (if applicable): Indicates a No response to the question, Do you lease workers
from a professional employer organization (PEO)?.
SUPPLEMENTAL
INFORMATION
Name of Professional
Employer Organization
(PEO)
Enter text: The full name of the employer organization (PEO).
SUPPLEMENTAL
INFORMATION
Do you lease workers to a
client company? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you lease workers
to a client company?. As used here, refer to the WCIP state instruction sheet for state
requirements.
SUPPLEMENTAL
INFORMATION
Do you lease workers to a
client company? No
Check the box (if applicable): Indicates a No response to the question, Do you lease workers
to a client company?.
SUPPLEMENTAL
INFORMATION
Are you seeking to cover the
leased workers? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are you seeking to
cover the leased workers?. As used here, refer to the WCIP state instruction sheet for state
requirements.
SUPPLEMENTAL
INFORMATION
Are you seeking to cover the
leased workers? No
Check the box (if applicable): Indicates a No response to the question, Are you seeking to
cover the leased workers?.
SUPPLEMENTAL
INFORMATION
Do you provide temporary
arrangement services to
other employers? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you provide
temporary arrangement services to other employers?. As used here, if YES, provide a
completed Temporary Labor Contractor Employee form.
SUPPLEMENTAL
INFORMATION
Do you provide temporary
arrangement services to
other employers? No
Check the box (if applicable): Indicates a No response to the question, Do you provide
temporary arrangement services to other employers?.
SUPPLEMENTAL
INFORMATION
Do you have a franchise or
licensing agreement? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you have a
franchise or licensing agreement?. As used here, If YES, provide a copy of the agreement.
SUPPLEMENTAL
INFORMATION
Do you have a franchise or
licensing agreement? No
Check the box (if applicable): Indicates a No response to the question, Do you have a
franchise or licensing agreement?.
SUPPLEMENTAL
INFORMATION
Is coverage requested for a
sports team? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is coverage
requested for a sports team?. As used here, if YES, provide the name of the sports team and
domiciled state in the space provided.
SUPPLEMENTAL
INFORMATION
Is coverage requested for a
sports team? No
Check the box (if applicable): Indicates a No response to the question, Is coverage requested
for a sports team?.
SUPPLEMENTAL
INFORMATION
Name of Sports Team
Enter text: The name of a sports team for which coverage is being requested.
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SUPPLEMENTAL
INFORMATION
Domiciled State
Enter text: The state or province code where a sports team is domiciled.
SUPPLEMENTAL
INFORMATION
Do trucking classifications
apply? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do trucking
classifications apply?. As used here, if yes, complete questions 13 - 20.
SUPPLEMENTAL
INFORMATION
Do trucking classifications
apply? No
Check the box (if applicable): Indicates a No response to the question, Do trucking
classifications apply?.
SUPPLEMENTAL
INFORMATION
Do you or your employees
regularly operate from a
base terminal(s) which is
(are) used to load, unload,
store or transfer freight?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you or your
employees regularly operate from a base terminal(s) which is (are) used to load, unload, store
or transfer freight?. As used here, if YES, list the complete address for each base terminal
which is used by the drivers to load, unload, and/or transfer freight on a regular basis.
SUPPLEMENTAL
INFORMATION
Do you or your employees
regularly operate from a
base terminal(s) which is
(are) used to load, unload,
store or transfer freight? No
Check the box (if applicable): Indicates a No response to the question, Do you or your
employees regularly operate from a base terminal(s) which is (are) used to load, unload, store
or transfer freight?.
SUPPLEMENTAL
INFORMATION
#1 Street
Enter text: The first address line of the physical location.
SUPPLEMENTAL
INFORMATION
#1 City
Enter text: The city of the physical location.
SUPPLEMENTAL
INFORMATION
#1 County
Enter text: The county of the physical location.
SUPPLEMENTAL
INFORMATION
#1 ST
Enter code: The state or province of the physical location.
SUPPLEMENTAL
INFORMATION
#1 Zip Code
Enter code: The postal code of the physical location.
SUPPLEMENTAL
INFORMATION
#2 Street
Enter text: The first address line of the physical location.
SUPPLEMENTAL
INFORMATION
#2 City
Enter text: The city of the physical location.
SUPPLEMENTAL
INFORMATION
#2 County
Enter text: The county of the physical location.
SUPPLEMENTAL
INFORMATION
#2 ST
Enter code: The state or province of the physical location.
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SUPPLEMENTAL
INFORMATION
#2 Zip Code
Enter code: The postal code of the physical location.
SUPPLEMENTAL
INFORMATION
#3 Street
Enter text: The first address line of the physical location.
SUPPLEMENTAL
INFORMATION
#3 City
Enter text: The city of the physical location.
SUPPLEMENTAL
INFORMATION
#3 County
Enter text: The county of the physical location.
SUPPLEMENTAL
INFORMATION
#3 ST
Enter code: The state or province of the physical location.
SUPPLEMENTAL
INFORMATION
#3 Zip Code
Enter code: The postal code of the physical location.
SUPPLEMENTAL
INFORMATION
Can each driver's state or
majority driving time be
established through
verifiable records or logs?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Can each driver's
state of majority driving time be established through verifiable records or logs?. As used here, If
the state of majority driving time can be established for each driver through verifiable logs or
records, list the state for each driver in the appropriate section of question 15.
SUPPLEMENTAL
INFORMATION
Can each driver's state or
majority driving time be
established through
verifiable records or logs?
No
Check the box (if applicable): Indicates a No response to the question, Can each driver's
state of majority driving time be established through verifiable records or logs?.
SUPPLEMENTAL
INFORMATION
#1 Driver Name
Enter text: The driver's full name.
SUPPLEMENTAL
INFORMATION
#1 Terminal #
Enter number: The producer assigned number of the location.
SUPPLEMENTAL
INFORMATION
#1 Majority Driving State
Enter code: The state or province where the driver does the majority of their driving.
SUPPLEMENTAL
INFORMATION
#1 Residence State
Enter code: The state or province of the driver.
SUPPLEMENTAL
INFORMATION
#2 Driver Name
Enter text: The driver's full name.
SUPPLEMENTAL
INFORMATION
#2 Terminal #
Enter number: The producer assigned number of the location.
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SUPPLEMENTAL
INFORMATION
#2 Majority Driving State
Enter code: The state or province where the driver does the majority of their driving.
SUPPLEMENTAL
INFORMATION
#2 Residence State
Enter code: The state or province of the driver.
SUPPLEMENTAL
INFORMATION
#3 Driver Name
Enter text: The driver's full name.
SUPPLEMENTAL
INFORMATION
#3 Terminal #
Enter number: The producer assigned number of the location.
SUPPLEMENTAL
INFORMATION
#3 Majority Driving State
Enter code: The state or province where the driver does the majority of their driving.
SUPPLEMENTAL
INFORMATION
#3 Residence State
Enter code: The state or province of the driver.
SUPPLEMENTAL
INFORMATION
What type(s) of goods are
being hauled?
Enter text: The type(s) of goods that are being hauled.
SUPPLEMENTAL
INFORMATION
Do you own these goods?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you own goods
that are being hauled?.
SUPPLEMENTAL
INFORMATION
Do you own these goods?
No
Check the box (if applicable): Indicates a No response to the question, Do you own goods that
are being hauled?.
SUPPLEMENTAL
INFORMATION
Is applicant under exclusive
contract with any retail
store(s)? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is applicant under
exclusive contract with any retail stores?. As used here, if YES, provide a copy of contract(s).
SUPPLEMENTAL
INFORMATION
Is applicant under exclusive
contract with any retail
store(s)? No
Check the box (if applicable): Indicates a No response to the question, Is applicant under
exclusive contract with any retail stores?.
SUPPLEMENTAL
INFORMATION
Is applicant under exclusive
contract with any postal
service? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is applicant under
exclusive contract with any postal service?. As used here, if YES, provide a copy of
contract(s).
SUPPLEMENTAL
INFORMATION
Is applicant under exclusive
contract with any postal
service? No
Check the box (if applicable): Indicates a No response to the question, Is applicant under
exclusive contract with any postal service?.
SUPPLEMENTAL
INFORMATION
Within what mile radius is
hauling done?
Enter number: The radius in whole numbers within which hauling is done.
Form Page 2
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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).
INSURANCE COMPANIES
WHO HAVE
OFFERED/REFUSED
INSURANCE
Have you received any
offers of voluntary
coverage? Yes
Check the box (if applicable): Indicates a Yes response to the question, Have you received
any offers of voluntary coverage?. As used here, an offer of voluntary coverage will affect an
applicant's eligibility for Plan coverage; therefore voluntary offers of coverage must be fully and
completely described including plan terms.
INSURANCE COMPANIES
WHO HAVE
OFFERED/REFUSED
INSURANCE
Have you received any
offers of voluntary
coverage? No
Check the box (if applicable): Indicates a No response to the question, Have you received any
offers of voluntary coverage?.
INSURANCE COMPANIES
WHO HAVE
OFFERED/REFUSED
INSURANCE
Explain
Enter text: An explanation of a response to a general information or underwriting question.
Normally, Yes responses require an explanation.
INSURANCE COMPANIES
WHO HAVE
OFFERED/REFUSED
INSURANCE
Indicate the number of
insurance companies which
have refused the applicant
coverage in the last 60 days
(or in accordance with state
specific guidelines)
Enter number: The number of insurance companies that have refused the applicant coverage in
the past specified time. As used here, refer to the state instructions for requirements regarding
the number of refusals needed before an applicant is eligible for the state's WCIP coverage.
Refusal must come from non-affiliated insurers who are licensed and actively writing workers
compensation insurance in the state of application. The employer and/or its representative must
retain in file the refusing carrier's name, contact person, address, phone number and date of
refusal.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Company Name One
Enter text: The full name of an insurer that has rejected coverage for the applicant.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Representative Name One
Enter text: The full name of the representative of the insurer that has rejected coverage for the
applicant.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Telephone Number One
Enter number: The phone number of the insurer rejecting coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Date of Refusal One
Enter date: The date the insurer refused coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Comments One
Enter text: The comments regarding the refusal of insurance.
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INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Company Name Two
Enter text: The full name of an insurer that has rejected coverage for the applicant.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Representative Name Two
Enter text: The full name of the representative of the insurer that has rejected coverage for the
applicant.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Telephone Number Two
Enter number: The phone number of the insurer rejecting coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Date of Refusal Two
Enter date: The date the insurer refused coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Comments Two
Enter text: The comments regarding the refusal of insurance.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Company Name Three
Enter text: The full name of an insurer that has rejected coverage for the applicant.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Representative Name Three
Enter text: The full name of the representative of the insurer that has rejected coverage for the
applicant.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Telephone Number Three
Enter number: The phone number of the insurer rejecting coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Date of Refusal Three
Enter date: The date the insurer refused coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Comments Three
Enter text: The comments regarding the refusal of insurance.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Company Name Four
Enter text: The full name of an insurer that has rejected coverage for the applicant.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Representative Name Four
Enter text: The full name of the representative of the insurer that has rejected coverage for the
applicant.
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INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Telephone Number Four
Enter number: The phone number of the insurer rejecting coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Date of Refusal Four
Enter date: The date the insurer refused coverage.
INSURANCE COMPANIES
WHO HAVE OFFERED/
REFUSED INSURANCE
Comments Four
Enter text: The comments regarding the refusal of insurance.
PREMIUM PAYMENT
Is the premium financed
through a third party
premium finance company?
Yes
Check the box (if applicable): Indicates the premium has been financed. As used here, if YES,
provide a copy of the agreement.
PREMIUM PAYMENT
Is the premium financed
through a third party
premium finance company?
No
Check the box (if applicable): Indicates the premium has not been financed.
PREMIUM PAYMENT
In applicable jurisdictions
on qualifying risk, is the
loss sensitive rating
program (LSRP)
contingency deposit being
paid in full at this time? Yes
Check the box (if applicable): Indicates a Yes response to the question, In applicable
jurisdictions on qualifying risks, is the loss sensitive rating program (LSRP) contingency deposit
being paid in full at this time?.
PREMIUM PAYMENT
In applicable jurisdictions
on qualifying risk, is the
loss sensitive rating
program (LSRP)
contingency deposit being
paid in full at this time? No
Check the box (if applicable): Indicates a No response to the question, In applicable
jurisdictions on qualifying risks, is the loss sensitive rating program (LSRP) contingency deposit
being paid in full at this time?.
REMARKS
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
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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APPLICANT'S STATEMENT
Statement
Enter text: The description of any difficulties the applicant has had with any producer or
company in regard to handling of any claim or accident report. As used here, list any exceptions
with regard to bona fide disputes in the space provided. The Loss Sensitive Rating Plan
acknowledgement applies only in those jurisdictions where the program has been approved for
use.
Reminder: Both the 130 and 133 applications must be signed by the insured and the producer.
APPLICANT'S STATEMENT
The insured elects to be
excluded from the list of
employers in the Tennessee
assigned risk plan - YES
(checkbox)
Check the box (if applicable): Indicates the insured elects to be excluded from the list of
employers in the Tennessee assigned risk plan.
APPLICANT'S STATEMENT
The insured elects to be
excluded from the list of
employers in the Tennessee
assigned risk plan - NO
(checkbox)
Check the box (if applicable): Indicates the insured does not elect to be excluded from the list of
employers in the Tennessee assigned risk plan.
APPLICANT'S STATEMENT
Applicant consents and
agrees to receive
electronically transmitted
information issued by NCCI
- YES (checkbox)
Check the box (if applicable): Indicates applicant consents and agrees to receive electronically
transmitted information issued by NCCI.
APPLICANT'S STATEMENT
Applicant consents and
agrees to receive
electronically transmitted
information issued by NCCI
- NO (checkbox)
Check the box (if applicable): Indicates applicant does not consent and agree to receive
electronically transmitted information issued by NCCI.
APPLICANT'S STATEMENT
Applicant's e-mail address
Enter text: The named insured's primary e-mail address.
APPLICANT'S STATEMENT
Applicant consents and
agrees to receive
electronically transmitted
information issued by the
assigned carrier - YES
(checkbox)
Check the box (if applicable): Indicates applicant consents and agrees to receive electronically
transmitted information issued by the assigned carrier.
APPLICANT'S STATEMENT
Applicant consents and
agrees to receive
electronically transmitted
information issued by the
assigned carrier - NO
(checkbox)
Check the box (if applicable): Indicates applicant does not consent and agree to receive
electronically transmitted information issued by the assigned carrier.
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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).
APPLICANT'S STATEMENT
Applicant's e-mail address
Enter text: The named insured's primary e-mail address.
APPLICANT'S STATEMENT
Applicant's Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
APPLICANT'S STATEMENT
Signature
Sign here: Accommodates the signature of the applicant or named insured. As used here, this
application must be signed by an officer, owner or partner. If a person other than any of these
has signed the application (e.g., spouse, trustee, general manager), attach a copy of the power
of attorney. With the signature, provide the signer's name, title and signature date.
APPLICANT'S STATEMENT
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
PRODUCER
COMMUNICATIONS
Producer consents and
agrees to receive
electronically transmitted
information issued by NCCI
- YES (checkbox)
Check the box (if applicable): Indicates producer consents and agrees to receive electronically
transmitted information issued by NCCI.
PRODUCER
COMMUNICATIONS
Producer consents and
agrees to receive
electronically transmitted
information issued by NCCI
- NO (checkbox)
Check the box (if applicable): Indicates producer does not consent and agree to receive
electronically transmitted information issued by NCCI.
PRODUCER
COMMUNICATIONS
Producer's e-mail address
Enter text: The producer's contact person's e-mail address.
PRODUCER
COMMUNICATIONS
Producer consents and
agrees to receive
electronically transmitted
information issued by the
assigned carrier - YES
(checkbox)
Check the box (if applicable): Indicates producer consents and agrees to receive electronically
transmitted information issued by the assigned carrier.
PRODUCER
COMMUNICATIONS
Producer consents and
agrees to receive
electronically transmitted
information issued by the
assigned carrier - NO
(checkbox)
Check the box (if applicable): Indicates producer does not consent and agree to receive
electronically transmitted information issued by the assigned carrier.
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PRODUCER
COMMUNICATIONS
Producer's e-mail address
Enter text: The producer's contact person's e-mail address.
PRODUCER'S
CERTIFICATION
Agency FEIN
Enter identifier: The producer's tax identification number.
PRODUCER'S
CERTIFICATION
Agency License 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.
PRODUCER'S
CERTIFICATION
Agency Phone Number
Enter number: The producer's contact person's phone number. If applicable, include the area
code and extension.
PRODUCER'S
CERTIFICATION
Agency Fax Number
Enter number: The fax number of the producer / agency.
PRODUCER'S
CERTIFICATION
Resident License Number
Enter identifier: The State License Number of the producer.
PRODUCER'S
CERTIFICATION
State
Enter code: The state or province code of the producer's resident license.
PRODUCER'S
CERTIFICATION
Expiration Date
Enter date: The date the producer's state license expires.
PRODUCER'S
CERTIFICATION
Non-Resident License
Number
Enter identifier: The producer's non-resident license number.
PRODUCER'S
CERTIFICATION
State
Enter code: The state or province code of the producer's non-resident license.
PRODUCER'S
CERTIFICATION
Expiration Date
Enter date: The date the producer's non-resident license expires.
PRODUCER'S
CERTIFICATION
Producer Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
PRODUCER'S
CERTIFICATION
E-Mail Address
Enter text: The producer's contact person's e-mail address.
PRODUCER'S
CERTIFICATION
Producer 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.
PRODUCER'S
CERTIFICATION
Date
Enter date: The date the producer signed the form.
ACORD 133 (2015/05) rev. 04-29-2015
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