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HOW TO COMPLETE AN ACORD APPLICATION FOR
WORKERS’ COMPENSATION INSURANCE

  • Indicated areas of the application must be completed. Get Acord Application
  • Please use these instructions to assist you with completing the Acord application.

Page One

  1. Applicant Name:  Provide full name of the applicant including DBA’s.
  2. Mailing Address:  Provide mailing address of the applicant.
  3. Years In Business:  Number of years applicant has been in business.
  4. Entity:  Indicate whether applicant is an individual, partnership, or corporation.
  5. Federal Employer ID Number:  9 digit federal ID number
  6. Locations:  Provide all physical locations for the applicant.
  7. Proposed Effective Date:  Provide the proposed effective and expiration dates.
  8. Part 1 (States):  Show CA for California; NV for Nevada
  9. Rating Information:  Provide respective class codes, *classification description, number of employees (full and part-time), and remuneration (payroll) in that class.

*A copy of the firms declaration page of their current coverage will assist in determining classifications.

Page Two

  1. Individuals Included/Excluded:  List all officers or partners to be included or excluded from coverage, including titles and ownership percentage totaling 100%.  Normally owners are excluded from coverage, but if they elect to be included they will be subject to the minimum/maximum payroll rule and charged for coverage.
  1. Prior Carrier Information:  Provide currently valued loss runs from the prior carrier for the past three years.  This information may be obtained by requesting the prior carrier (applications over $50,000 in premium require 4 years of loss runs) to fax the current loss runs to your fax or ours (800) 292-2149.