ACORD 130 Fillable PDF – Workers Compensation Form
ACORD 130 (2010/05)
Workers Compensation Application
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Form Number: |
ACORD 130 (2010/05) |
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Category: |
Commercial Lines |
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Last Updated: |
May 2010 |
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Page Count: |
04 page |
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File Format: |
PDF, Fillable PDF |
Acord 130 Form
It is an official and standardized application form used by insurers, brokers, and businesses to request compensation insurance coverage, evaluate a business’s risk level, calculate premiums, payroll, prior claims, and evaluate employee classifications. AcordForms.net offers a ready-to-use and submit fillable and downloadable Acord 130 form for free. Fill out online or download the document now and make your submission easier with us!
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Benefits of Using Fillable Acord 130 Form?
Multi-State Coverage
Acord 130 fillable form supports multiple operational states, such as Florida, Texas, California, and NSW, making it easier to add details for businesses operating across multiple states.
Accuracy
Each fillable text field or column reduces the chances of errors, mistakes, and repetition, making the more accurate and authentic.
Support Digital Submission
AcordForm.net provides fillable acord PDF forms, allowing users to complete it digitally and submit via email or upload.
Useful For Audits
Well-organized and structured data helps insurers and businesses during policy audits, renewals, and coverage reviews.
Time-Saving
There is no need for complex multiple data sheets. It contains all the necessary fields in a single document, saving agents and employers a significant amount of time and keeping the underwriting and quoting process efficient.
Key Sections of Acord 130 Fillable PDF
Business Applicant Information
It is the first section of the document that contains the legal business name, nature of business, FEIN, address, and contact details.
Policy and Carrier Information
This part requires insurer details, desired effective and expiration date, and the states of coverage.
Business Details
Includes type of business, ownership, number of locations and branches, summary of daily business activities, and subcontractor usage.
Payroll and Employee Classification
The section contains the total number of employees, job classification, estimated payroll, and employee code.
Prior Insurance and Claims History
The bottom section of the acord 130 pdf form contains workers’ compensation coverage, claims made, loss experience, prior insurer details, and more.
Signature
It requires the authorized signature of the applicant and the insurance agent.
How to Fill Out Workers Comp Acord 130?
- Access online or download the fillable PDF form.
- Enter the business information, such as business name, FEIN (Federal Employer Identification Number), address, phone number, fax number, and email address.
- Write the applicant’s name, address, phone number, and email address of a new agent.
- Mention the policy’s effective date and expiration date.
- Applicable state for coverage, such as Florida, California, Texas, etc.
- Briefly explain what your business does, how long it has been operating, locations, and subcontractors.
- List employees’ classification and payroll, including the estimated annual payroll for each employee, the total number of employees, and classification codes available through NCCI.
- Enter the coverage dates, lapse periods, and previous insurance carrier.
- Input the loss history, such as date of loss, incurred amount, prior claims, type of injury, etc.
- Get the insured’s signature and mention the date.
Frequently Asked Questions
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