ACORD 130 Fillable | Workers Compensation Application

Agents use the Workers Compensation Application to apply for workers’ comp coverage on a business’s own employees. This form is separate from its cousin, ACORD 125, the general commercial application, because workers’ comp needs its own details: payroll by job classification, prior claims, and which states employees actually work in. The business owner supplies that information, and no employee fills it in.

Ten sections across four pages, in the order they appear.

1. 1

   Agency & Applicant

   The agency, producer, and underwriter handling the submission, and the applicant’s name, business type, and federal employer ID number.

2. 2

   Status & Billing

   Whether this is a quote or a bound policy, the billing plan, and how often the policy gets audited. There’s also an “assigned risk” box, checked when a business can’t get coverage through a regular carrier and gets placed through the state’s assigned risk pool instead, which requires attaching ACORD 133.

3. 3

   Locations

   Every address where the business operates, since workers’ comp rates and rules can differ by location and state.

4. 4

   Policy Information

   The states covered, the employer’s liability limits, deductibles, and any other coverages like U.S.L.&H. or voluntary compensation.

5. 5

   State Rating Worksheet

   A second page that repeats for every state the business operates in, listing class codes, job duties, and payroll for each one. This is the one section that genuinely grows with the business: one state means one worksheet, five states means five.

6. 6

   Individuals Included / Excluded

   Owners, partners, and officers, and whether the policy covers each one or leaves them out. Missouri has its own specific rule for who qualifies for exclusion.

7. 7

   Prior Carrier & Loss History

   Five years of past carriers, premiums, and claims, including whether you attach a loss run.

8. 8

   Nature of Business

   A written description of what the business actually does, written clearly enough for an underwriter to picture the operation.

9. 9

   General Information

   Twenty-four yes/no questions, covering things like hazardous materials, work above 15 feet, seasonal employees, and remote workers. One is worth pausing on: if the business uses subcontractors without their own certificates of insurance, it has to include their payroll on its own rating worksheet instead, which can raise the premium more than people expect. Every yes needs an explanation.

10. 10

    Remarks & Signature

    Extra space for anything that didn’t fit elsewhere, followed by the applicant’s and producer’s signatures.

Most of this form is background detail. One figure on it, the experience modification factor, does more to set the final premium than anything else. It’s a number, usually close to 1.0, that adjusts the standard rate up or down based on the business’s own claims history compared to similar businesses. A business with fewer claims than expected gets a mod below 1.0 and pays less. One with more claims gets a mod above 1.0 and pays more. This is exactly why agents keep asking for loss runs and accurate payroll figures before they can finish submitting this form, without them, nobody can calculate the mod, and without the mod, nobody can quote an accurate price.

Often, yes. The Individuals Included/Excluded section lets owners, partners, and officers choose to opt out of coverage, which lowers the premium since their payroll no longer factors into the rate. Whether you can actually do this depends on the state and the business structure, and some states cap how many owners can exclude themselves or require specific wording. Missouri, for example, only allows it if the exclusion meets the requirements of Section 287.090 RSMo. It’s worth asking directly rather than assuming you can just check the box.

Every job on the rating worksheet gets its own code, a short number that tells the insurer what kind of work it is. That code matters more than almost anything else on this form, because it decides the price. A roofer and an office worker at the same company get charged completely differently, since one job is simply more dangerous than the other. Picking the wrong code, even by accident, can mean paying too much for years, or not enough and owing money later. If a job is hard to categorize, it’s worth just asking the agent instead of guessing.

Payroll drives the price, but nobody knows the exact payroll for the whole year on day one, so the quote starts as a guess. Later, the insurer checks that guess against what the business actually paid its workers. That check is an audit, and the form lets you pick how often it happens. Paid more than expected? Expect a bill. Paid less? Money comes back. It surprises a lot of business owners who think the first number is the only number.

Most of this form reads the same no matter where it’s filled out. The fraud warning near the signature doesn’t. A handful of states skip the usual wording entirely and use their own instead, written specifically for that state’s laws. It doesn’t change what counts as an honest answer, lying on the form is a bad idea everywhere, but it’s worth knowing this page isn’t identical everywhere it’s used.