What Is an ACORD 130 Form?​

Acord 130 Logo

If you’re beginning a career in insurance, it’s important to learn about the applications like the ACORD 130 used in the Agency Management System (AMS).

ACORD forms, created by the ACORD Corporation, are standardized documents recognized across the insurance industry. They include all the details insurers require to issue quotes. Different ACORD forms exist for specific coverage types, and a common one you’ll encounter is the ACORD 130

The ACORD 130 form, more widely known as the Workers Compensation Application, is used to gather policy data needed to rate workers compensation. This workers compensation insurance application includes critical information like remuneration (payroll), loss history, and other operational details.

You might wonder how to fill out ACORD 130. In short, it’s essential, because this workers comp application is needed for every workers compensation policy. Some insurance professionals refer to it as the ACORD application for brevity.

Let’s explore the main areas to focus on when completing an ACORD 130.

Page 1: Core Details - ACORD 130

Agency and Applicant Information

Start by entering your agency information. If you’re using an AMS, it may auto-populate. Otherwise, input the required data manually. Next, fill in the Applicant Information on the right side of the page:

  • Applicant name
  • Phone number(s)
  • Years in Business
  • Mailing address
  • Applicant Entity Type
  • ID Number (if applicable)
  • Federal Employer ID Number (EIN)
ACORD 130 workers compensation application capturing agency details, applicant entity type, years in business, and federal employer ID information.

Submission and Billing Details - ACORD 130

Below that, choose the Status of Submission—for new quotes, select “quote.” Under Billing/Audit Information, note who gets billed (the insured or the agency) and identify the chosen premium payment plan. There’s also a space to indicate the policy’s audit frequency.

ACORD 130 workers compensation submission and billing section showing status (quote, bound, assigned risk), billing plan (agency or direct), payment plan, and audit frequency.

The next area you will find in the ACORD 130 is the Locations section. Here you will need to enter the location number and full address for the insured. Use additional lines as needed to record all of the insured’s locations, including any work from home arrangements.

Locations Section

List each insured location, including any work from home setups. If there are multiple sites, add them on additional lines.

ACORD 130 workers compensation locations section listing multiple insured sites, including addresses and highest floors for each workplace.

Policy Information - ACORD 130

Use this section to record:

  • Effective and expiration dates
  • State(s) where the insured operates (including any ACORD 130 FL specific information for Florida)
  • Employer’s liability limits
  • Other states the insured might need coverage in

Contact Information - ACORD 130

If you’ve completed the ACORD 125 for the same client, you can skip this area. If not, enter the applicant’s contact details.

Individuals Included/Excluded

Here, identify owners, partners, officers, or relatives and indicate whether they’re included or excluded from workers compensation benefits. Supply details such as state, location number, title, ownership percentage, and remuneration.

ACORD 130 workers compensation form section listing owners, partners, officers, or relatives, with details on inclusion/exclusion, ownership percentage, and remuneration.

State Rating Worksheet & Premium Information - ACORD 130

On Page 2, you’ll find the State Rating Worksheet, where you detail each location’s specific job duties. Include:

  • Class code
  • Categories
  • Duties and classifications
  • Number of full-time and part-time employees

If payroll is broken down by various tasks, list each task separately with the appropriate class codes. This can lower the minimum premium if done correctly.

ACORD 130 workers compensation state rating worksheet capturing codes, duties, number of full-time and part-time employees, and payroll breakdowns for each location.

Premium Section - ACORD 130

Focus on the Experience Mod, assigned by NCCI (National Council on Compensation Insurance) based on loss history. An insured with three years of workers’ comp experience and a premium over $3,000 might have an experience modification. A modifier under 1.0 lowers costs; one above 1.0 raises premiums.

Other items here include:

  • Premium discount
  • Deposit premium
  • Any consideration for assigned risk
  • Rating information
ACORD 130 workers compensation premium section featuring experience modification, assigned risk factors, premium discounts, deposit premiums, and overall rating information.

Policy History & Business Operations - ACORD 130

Prior Carrier & Loss History

Document the last five years of coverage, including prior carrier information:

  • Policy year
  • Carrier name
  • Policy number
  • Premium
  • Experience Mod (if any)
  • Claim counts and claim amounts (paid or reserved)

This is key for NCCI when calculating the experience modification factor.

workers compensation form listing prior carrier details, policy years, premiums, experience modifications, and claims history for the last five years.

Nature of Business

Use this area to describe the insured’s operations, including any subcontractors or leased employees. If you’re not submitting ACORD 125, you must fill this out.

workers compensation form section describing the insured’s operations, including any subcontractors, leased employees, and manufacturing or service details.

General Information Section

Spread across Page 3 and Page 4, this part has 24 yes/no questions covering:

  • Safety programs
  • Seasonal employees
  • Physical handicaps of employees
  • Whether coverage declined in the past
  • Bankruptcy and tax liens

Any “yes” requires an explanation. Pay special attention to questions about safety program implementation, as this can affect premiums.

general information section spanning pages 3 and 4, featuring 24 yes/no questions about safety programs, seasonal employees, prior coverage declines, and other underwriting details.

Finalizing the Form

At the bottom, you’ll see signature boxes for both the producer and insured. While these aren’t required for a quote, they are necessary to bind the policy.

Additional Notes

  • A fillable ACORD 130 form is generally found in your AMS.
  • You can send an ACORD form PDF to the client for review and signature.
  • Some data auto-fills in the AMS, saving time.

The ACORD 130 is critical for issuing workers compensation insurance. It allows carriers to review policy information, loss history, and other risk factors to price coverage appropriately. By filling it out accurately, you ensure clients get the coverage they need.

Remember to consider the NCCI risk ID for experience rating when working with ACORD 130.

Within the form, you’ll see sections for rating information and schedule rating, both of which help determine the estimated annual premium. Accurately completing them ensures the premium is calculated properly.

Stay informed of updates to the ACORD 130 form, as industry requirements evolve. Always use the most recent version of the ACORD 130 to remain compliant.