Fillable WORKERS COMPENSATION APPLICATION (Valley Forge Insurance Brokerage)

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WORKERS COMPENSATION APPLICATION (Valley Forge Insurance Brokerage)

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© 1980-2009 ACORD CORPORATION. All rights reserved.Page 1 of 4ACORD 130 (2009/09)
MONTHLY
QUARTERLY
SEMI-ANNUAL
AT EXPIRATION
AUDIT
% DOWN:QUARTERLY
SEMI-ANNUAL
ANNUAL
PAYMENT PLAN
STATUS OF SUBMISSION BILLING / AUDIT INFORMATION
QUOTE ISSUE POLICY
BOUND (Give date and/or attach copy)
ASSIGNED RISK (Attach ACORD 133) DIRECT BILL
AGENCY BILL
BILLING PLAN
LOC #
STREET, CITY, COUNTY, STATE, ZIP CODE
LOCATIONS
OTHER COVERAGES
VOLUNTARY
COMP
FOREIGN COV
MANAGED
CARE OPTION
U.S.L. & H.
DIVIDEND PLAN/SAFETY GROUP ADDITIONAL COMPANY INFORMATION
INDEMNITY
MEDICAL
DEDUCTIBLES
(N / A in WI)
AMOUNT / %
(N / A in WI)
NORMAL ANNIVERSARY RATING DATE
NON-PARTICIPATING
PARTICIPATING
RETRO PLAN
POLICY INFORMATION
PROPOSED EFF DATE PROPOSED EXP DATE
PART 1 - WORKERS
COMPENSATION (States)
PART 2 - EMPLOYER'S LIABILITY
$
$
$
EACH ACCIDENT
DISEASE-POLICY LIMIT
DISEASE-EACH EMPLOYEE
PART 3 - OTHER
STATES INS
SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
The ACORD name and logo are registered marks of ACORD
NAME MOBILE PHONE E-MAIL
CONTACT INFORMATION
INSPECTION
ACCTNG
TYPE
RECORD
CLAIMS
INFO
OFFICE PHONE
TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES
TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES
$
TOTAL MINIMUM PREMIUM ALL STATES
$
TOTAL DEPOSIT PREMIUM ALL STATES
$
INDIVIDUALS INCLUDED / EXCLUDED
STATE LOC #
REMUNERATION/PAYROLLCLASS CODEINC/EXCDUTIES
SHIP %
OWNER-
RELATIONSHIP
TITLE/
DATE OF BIRTHNAME
PARTNERS, OFFICERS, RELATIVES ( Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.)
Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.
WORKERS COMPENSATION APPLICATION
DATE (MM/DD/YYYY)
YRS IN BUS:
NAICS:
MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code)
SOLE PROPRIETOR
PARTNERSHIP
CORPORATION
SUBCHAPTER "S" CORP
LLC
BUREAU NAME:
CREDIT
EMPLOYER REGISTRATION NUMBER
OTHER RATING BUREAU ID OR STATE
NCCI RISK ID NUMBERFEDERAL EMPLOYER ID NUMBER
SIC:
COMPANY:
UNDERWRITER:
ID NUMBER:
APPLICANT NAME:
OFFICE PHONE: MOBILE PHONE:
E-MAIL ADDRESS:
TRUST
JOINT VENTURE
WEBSITE
ADDRESS:
OTHER
AGENCY NAME AND ADDRESS
PHONE:
MOBILE
(A/C, No):
FAX
E-MAIL
ADDRESS:
SUB CODE:CODE:
AGENCY CUSTOMER ID:
(A/C, No, Ext)
OFFICE PHONE
NAME:
CS REPRESENTATIVE
PRODUCER NAME:
0.00
0.00
0.00
TIME
PART
TIME
FULL
RATE
# EMPLOYEES
CATEGORIES, DUTIES, CLASSIFICATIONSCLASS CODELOC # NAICSSIC
ESTIMATED ANNUAL
REMUNERATION/
PAYROLL
ESTIMATED
ANNUAL MANUAL
PREMIUM
DESCR
CODE
PREMIUM
$
$
EXPENSE CONSTANT $
PREMIUM DISCOUNT $
$
ARAP * $
ASSIGNED RISK SURCHARGE * $
$
$
$
$DEDUCTIBLE *
INCREASED LIMITS $
TOTAL $
STATE:
FACTOR
FACTORED PREMIUM
CCPAP
$
SCHEDULE RATING *
$
$STANDARD PREMIUM
TOTAL ESTIMATED ANNUAL PREMIUM MINIMUM PREMIUM DEPOSIT PREMIUM
$$$
FACTOR
EXPERIENCE OR MERIT
FACTORED PREMIUM
TAXES / ASSESSMENTS *
MODIFICATION
N / A
N / A
N / A
* N / A in Wisconsin
STATE RATING WORKSHEET
FOR MULTIPLE STATES, ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM
Page 2 of 4ACORD 130 (2009/09)
RATING INFORMATION - STATE:
STATE RATING SHEET # SHEETSOF
AGENCY CUSTOMER ID:
REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
1
1
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
YEAR CARRIER & POLICY NUMBER ANNUAL PREMIUM MOD # CLAIMS AMOUNT PAID RESERVE
LOSS RUN ATTACHED
PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS
PRIOR CARRIER INFORMATION / LOSS HISTORY
NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS
GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING - RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT; CONTRACTOR - TYPE
OF WORK, SUB-CONTRACTS; MERCANTILE - MERCHANDISE, CUSTOMERS, DELIVERIES; SERVICE - TYPE, LOCATION; FARM - ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS.
Page 3 of 4
1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?
EXPLAIN ALL "YES" RESPONSES
5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR
TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)
2.
GENERAL INFORMATION
12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If "YES", please specify)
11. ANY SEASONAL EMPLOYEES?
10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?
9. ANY GROUP TRANSPORTATION PROVIDED?
7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If "YES", payroll for this work must be included in the State Rating Worksheet on Page 2)
6. ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)
AGENCY CUSTOMER ID:
ACORD 130 (2009/09)
Y / N
17. ANY OTHER INSURANCE WITH THIS INSURER?
16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
EXPLAIN ALL "YES" RESPONSES
18. ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)
19. ARE EMPLOYEE HEALTH PLANS PROVIDED?
15. ARE ATHLETIC TEAMS SPONSORED?
14. DO EMPLOYEES TRAVEL OUT OF STATE? (If "YES", indicate state(s) of travel and frequency)
Page 4 of 4ACORD 130 (2009/09)
GENERAL INFORMATION (continued)
20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?
21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If "YES", # of Employees:
23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (If "YES", please specify)
ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES?
IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).
24.
13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
AGENCY CUSTOMER ID:
Y / N
NATIONAL PRODUCER NUMBERPRODUCER'S SIGNATUREDATEAPPLICANT'S SIGNATURE (Must be Officer, Owner or Partner)
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION
FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND
SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or
WA; in LA, ME, TN and VA, insurance benefits may also be denied)
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE
COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY
FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE
PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES.
APPLICABLE IN TENNESSEE AND VERMONT: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO
ANY PARTY TO A WORKERS COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
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WORKERS COMPENSATION APPLICATION (Valley Forge Insurance Brokerage)

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Completed 20 January 2022

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