Fillable WORKERS COMPENSATION APPLICATION

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WORKERS COMPENSATION APPLICATION

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PRODUCER NAME:
CS REPRESENTATIVE
NAME:
OFFICE PHONE
(A/C, No, Ext):
AGENCY CUSTOMER ID:
CODE: SUB CODE:
ADDRESS:
E-MAIL
FAX
(A/C, No):
MOBILE
PHONE:
AGENCY NAME AND ADDRESS
ASSOCIATION
OTHER:
"S" CORP
UNINCORPORATED
ADDRESS:
WEBSITE
JOINT VENTURE
TRUST
E-MAIL ADDRESS:
MOBILE PHONE:OFFICE PHONE:
APPLICANT NAME:
ID NUMBER:
UNDERWRITER:
COMPANY:
SIC:
FEDERAL EMPLOYER ID NUMBER NCCI RISK ID NUMBER
OTHER RATING BUREAU ID OR STATE
EMPLOYER REGISTRATION NUMBER
CREDIT
BUREAU NAME:
LLC
SUBCHAPTER
CORPORATION
PARTNERSHIP
SOLE PROPRIETOR
MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code)
NAICS:
YRS IN BUS:
DATE (MM/DD/YYYY)
WORKERS COMPENSATION APPLICATION
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.
NAME DATE OF BIRTH
TITLE/
RELATIONSHIP
OWNER-
SHIP %
DUTIES INC/EXC CLASS CODE REMUNERATION/PAYROLL
LOC #STATE
INDIVIDUALS INCLUDED / EXCLUDED
$
TOTAL DEPOSIT PREMIUM ALL STATES
$
TOTAL MINIMUM PREMIUM ALL STATES
$
TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES
TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES
OFFICE PHONE
INFO
CLAIMS
RECORD
TYPE
ACCTNG
INSPECTION
CONTACT INFORMATION
E-MAILMOBILE PHONENAME
The ACORD name and logo are registered marks of ACORD
SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
PART 3 - OTHER
STATES INS
DISEASE-EACH EMPLOYEE
DISEASE-POLICY LIMIT
EACH ACCIDENT
$
$
$
PART 2 - EMPLOYER'S LIABILITY
PART 1 - WORKERS
COMPENSATION (States)
PROPOSED EXP DATEPROPOSED EFF DATE
POLICY INFORMATION
RETRO PLAN
PARTICIPATING
NON-PARTICIPATING
ANNIVERSARY RATING DATE
AMOUNT / %
(N / A in WI)
(N / A in WI)
DEDUCTIBLES
MEDICAL
INDEMNITY
ADDITIONAL COMPANY INFORMATIONDIVIDEND PLAN/SAFETY GROUP
U.S.L. & H.
CARE OPTION
MANAGED
FOREIGN COV
COMP
VOLUNTARY
OTHER COVERAGES
LOCATIONS
FLOOR
HIGHEST
STREET, CITY, COUNTY, STATE, ZIP CODE
LOC #
BILLING PLAN
AGENCY BILL
DIRECT BILLASSIGNED RISK (Attach ACORD 133)
BOUND (Give date and/or attach copy)
ISSUE POLICYQUOTE
BILLING / AUDIT INFORMATIONSTATUS OF SUBMISSION
PAYMENT PLAN
ANNUAL
SEMI-ANNUAL
QUARTERLY % DOWN:
AUDIT
AT EXPIRATION
SEMI-ANNUAL
QUARTERLY
MONTHLY
ACORD 130 (2017/05) Page 1 of 4 © 1980-2017 ACORD CORPORATION. All rights reserved.
RATING EFFECTIVE DATE
(if applicable) (if applicable)
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AGENCY CUSTOMER ID:
OF SHEETSSTATE RATING SHEET #
RATING INFORMATION - STATE:
Page 2 of 4
FOR MULTIPLE STATES, ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM
STATE RATING WORKSHEET
* N / A in Wisconsin
N / A
N / A
N / A
MODIFICATION
TAXES / ASSESSMENTS *
FACTORED PREMIUM
EXPERIENCE OR MERIT
FACTOR
$ $ $
DEPOSIT PREMIUMMINIMUM PREMIUMTOTAL ESTIMATED ANNUAL PREMIUM
STANDARD PREMIUM $
$
SCHEDULE RATING *
$
CCPAP
FACTORED PREMIUM
FACTOR
STATE:
$TOTAL
$INCREASED LIMITS
DEDUCTIBLE * $
$
$
$
$ASSIGNED RISK SURCHARGE *
$ARAP *
$
$PREMIUM DISCOUNT
$EXPENSE CONSTANT
$
$
PREMIUM
DESCR
CODE
ESTIMATED
ANNUAL MANUAL
PREMIUM
ESTIMATED ANNUAL
REMUNERATION/
PAYROLL
SIC NAICSLOC # CLASS CODE CATEGORIES, DUTIES, CLASSIFICATIONS
# EMPLOYEES
RATE
FULL
TIME
PART
TIME
TERRORISM
CATASTROPHE
N / A
N / A
ACORD 130 (2017/05)
16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?
15. ARE ATHLETIC TEAMS SPONSORED?
13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?
14. DO EMPLOYEES TRAVEL OUT OF STATE? (If "YES", indicate state(s) of travel and frequency)
Y / N
AGENCY CUSTOMER ID:
6. ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)
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)
9. ANY GROUP TRANSPORTATION PROVIDED?
8. IS A WRITTEN SAFETY PROGRAM IN OPERATION?
10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?
11. ANY SEASONAL EMPLOYEES?
12. IS THERE ANY VOLUNTEER OR DONATED LABOR? (If "YES", please specify)
GENERAL INFORMATION
2.
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)
3.
ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?
4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?
5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?
EXPLAIN ALL "YES" RESPONSES
1.
DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?
Page 3 of 4
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.
NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS
PRIOR CARRIER INFORMATION / LOSS HISTORY
PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS
LOSS RUN ATTACHED
RESERVEAMOUNT PAID# CLAIMSMODANNUAL PREMIUMCARRIER & POLICY NUMBERYEAR
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
POL #:
CO:
ACORD 130 (2017/05)
Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a
false statement as to any material fact may be violating state law.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties (not to exceed five thousand dollars and
the stated value of the claim for each such violation)*. *Applies in NY Only.
Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps,
or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss,
shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty
thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2)
years.
Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be
presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or
telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows
to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or
benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison. *Applies in MD Only.
Applicable in UT: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for
disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a
crime and may be subject to fines and confinement in state prison.
(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.)
(Applicant's Initials):
18. ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)
17. ANY OTHER INSURANCE WITH THIS INSURER?
SIGNATURE
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS
OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS
OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE
PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO
REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN
WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY
BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON
HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
APPLICANT'S SIGNATURE (Must be Officer, Owner or Partner)
DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER
Y / N
AGENCY CUSTOMER ID:
24.
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).
23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (If "YES", please specify)
22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If "YES", # of Employees:
21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?
GENERAL INFORMATION (continued)
Page 4 of 4
19. ARE EMPLOYEE HEALTH PLANS PROVIDED?
EXPLAIN ALL "YES" RESPONSES
ACORD 130 (2017/05)
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WORKERS COMPENSATION APPLICATION

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Completed 22 February 2022

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