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
- Applicant Name: Provide full name of the applicant including DBA’s.
- Mailing Address: Provide mailing address of the applicant.
- Years In Business: Number of years applicant has been in business.
- Entity: Indicate whether applicant is an individual, partnership, or corporation.
- Federal Employer ID Number: 9 digit federal ID number
- Locations: Provide all physical locations for the applicant.
- Proposed Effective Date: Provide the proposed effective and expiration dates.
- Part 1 (States): Show CA for California; NV for Nevada
- 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
- 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.
- 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.