ACORD 130 Workers Compensation Section - Policy Information

How to Complete the Policy Information Section of the ACORD 130

Policy Information

PROPOSED EFF DATE: The proposed effective date for this policy. For data entry purposes most online forms will force you to use a database friendly format. Cap Dat ACORD forces DD/MM/YYYY. Example 01/01/2014.

PROPOSED EXP DATE:  The proposed expiration date for this policy. For data entry purposes most online forms will force you to use a database friendly format. Cap Dat ACORD forces DD/MM/YYYY. Example 01/01/2014.

NORMAL ANNIVERSARY RATING DATE: This will most likely be the same as the proposed effective date. The rating date is important for when any appropriate rating bureau would calculate an experience modification. Reasons the dates might not be the same could be purchase of insured by another company or mid term cancellation by a previous insurance carrier.

PARTICIPATING OR NON-PARTICIPATING:  (Quoted from the ACORD FIG) A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating basis. Check with your company on the availability of plans.

RETRO PLAN: This is a retrospective rating plan. It means that, subject to minimum and maximum premiums, the final actual premium will be computed after the policy period based on actual payroll and actual losses.

PART 1 - WORKERS COMPENSATION (STATES): Part 1 refers to the state by state workers compensation laws. List all states in which workers compensation is provided by this policy. Use the Remarks section at the bottom of page 2 if more space is needed.

PART 2 - EMPLOYER'S LIABILITY: Enter the limits for EACH ACCIDENT, DISEASE-POLICY LIMIT, DISEASE-EACH EMPLOYEE. Check with your underwriter to see what limits apply in each state.

PART 3 - OTHER STATES INS: Part 3 refers to states not listed in Part 1, but where your customer is likely to have operations at some point during this policy term.

DEDUCTIBLES (N/A IN WI): Check with your underwriter or an experienced agent in your office to see if deductibles apply in the states for which workers compensation coverage is being provided. These check boxes are not mutually exclusive. The third check box with no text is for any other deductible type.

AMOUNT / % (N/A WI): Enter the percentage amount or the hard dollar amount of the deductible. Example 1% or $1,000. Choose one format or the other. Check with your underwriter to see which applies, if any.

OTHER COVERAGES: Check all that apply.

U.S.L&H - United States Longshoremen's and Harbor Workers coverage

VOLUNTARY COMP: Voluntary Compensation

FORGEIN COV: Foreign coverage

MANAGED CARE OPTION

DIVIDEND PLAN/SAFETY GROUP: This is related to Participatory Plans. Check with your underwriter to get name of group.

ADDITIONAL COMPANY INFORMATION: This is a wide open area with anything else the company feels needs to be listed.

SPECIFY ADDITIONAL COVERAGES/ENDORSEMENT (ATTACH ACORD 101, ADDITIONAL REMARKS SCHEDULE, IF MORE SPACE IS NEEDED.): Anything you need on the policy, or endorsements you need to be issued with the policy should be listed here.

I hope this helps you better understand how to complete the ACORD 130 Workers Compensation Application.

Please share this with anyone you wish.