Part 3 How to Complete a Workers Compensation Application
The Carrier and Applicant information is in the top right hand corner of page 1 of the ACORD 130.
Carrier Info
COMPANY NAME: This is the name of the specific insurance carrier to whom you are sending the application.
UNDERWRITER: This is the name of the actual underwriter at the carrier to whom you are sending the application. You may not know this person's name.
Applicant Information
APPLICANT NAME: The full legal name of your customer as you need to have it show on the issued policy. Remember, this is how the name will appear on certificates of insurance and driver ID cards.
OFFICE PHONE: The main phone number for your customer's business.
MOBILE PHONE: If you have the person's permission, this would be the mobile phone number that the carrier's inspection staff could use to call your customer. Be certain you have your customer's permission.
MAILING ADDRESS: Post Office Box or street address in full. Includes the city, state and zip code. Normally you would fill this box in the so it looks just like you want it to look on an envelop. Example:
Atlatl, Inc.
P.O. Box 2936
Durham, NC 27715-2936
YRS IN BUS: In plain English this means years in business. You can put a hard number here or you can put the year the business opened. Then you do not have to change it every year at renewal. Example:
4 years 3 months
or,
Since March 2003
SIC: This stands for Standard Industrial Classifications. This is a system created by the U. S. government in 1937 for classifying industries. It was created in response to the problem of economists trying to compile data as a result of the Great Depression and realizing they had nothing much with which to work.
You can find SIC codes at sites such as...
https://www.osha.gov/pls/imis/sicsearch.html
or
http://www.naics.com/search/
NAICS: This is the North American Industry Classification System. you can find these numbers at the link above or at...
https://www.census.gov/eos/www/naics/
WEBSITE ADDRESS: The main website for your customer's business. If the business has more than one website, say a website for each product the company offers, you will want to indicate this in the remarks section later in the application.
EMAIL ADDRESS: This would be the email address at the business for the person working with you on the workers compensation application.
LEGAL ENTITY TYPE: Check the type of legal entity your customer uses. You will only check one type as these are mutually exclusive. If you are not certain, ask your customer.
CREDIT BUREAU NAME: I have actually never seen this filled in. This is the name of the specific credit bureau from whom the underwriter may choose to get a report. I have no idea how you would know this information.
ID NUMBER: This would be the ID number for this customer, but it is unclear whose ID number this would be - the carriers, your agency's, the credit bureaus? I would leave this blank.
FEDERAL EMPLOYER ID NUMBER: This is the Federal Tax ID number. It is in this format - 12-3456789. Ask your customer for this. They will have it.
NCCI RISK ID NUMBER: The National Council on Compensation Insurance number. If your customer is large enough to have a Workers Compensation experience rating modification, they will also have an NCCI number. This will mean they have had insurance for workers compensation. The number will be on their past policy.
If this is a new business, they will not have this number. Ask your underwriter about this. Let them help you with this input.
OTHER RATING BUREAU ID OR STATE EMPLOYER REGISTRATION NUMBER: Some states have their own ID numbers. Ask your underwriter for help. She will be vary familiar with the state by state issues for the states she underwrites.
That is a lot. You will not always fill out every single box with a response. Ask other agents in your office or your underwriter what information they need.
I hope this is helpful in teaching you how to complete the ACORD 130 Workers Compensation Application. Please share it with others.
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