ACORD 130 Workers Compensation Application
Captures applicant business operations, employee classifications, payroll by class code, hazard exposures, loss history, and state-specific rating factors for Workers Compensation underwriting.
- Form number
- Form ACORD 130
- Edition
- Edition ACORD 0130 2017-05r1 Acroform
- Fields
- 482 fields
- Pages
- 4 pages
What this form asks for
Examples from the PDF's 482 fields. Bindly uses the full field map to ask only the questions that apply.
- Form Edition Identifier
- Form Completion Date
- Producer Full Name
- Producer Mailing Address Line One
- Producer Mailing Address Line Two
- Producer Mailing Address City Name
- Producer Mailing Address State Or Province Code
- Producer Mailing Address Postal Code
- Producer Contact Person Full Name
- Producer Customer Service Representative Full Name
- Producer Contact Person Phone Number
- Producer Contact Person Cell Phone Number
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Frequently asked questions
- What is the ACORD 130 Workers Compensation Application?
- Captures applicant business operations, employee classifications, payroll by class code, hazard exposures, loss history, and state-specific rating factors for Workers Compensation underwriting. It is part of Bindly's library of 3,000+ insurance forms.
- Where can I download the ACORD 130 Workers Compensation Application?
- You can preview and download the blank ACORD 130 Workers Compensation Application PDF for free on Bindly's form library, or have Bindly fill it for you automatically. No login is required to preview or download.
- How do I fill out the ACORD 130 Workers Compensation Application?
- Bindly interviews the insured in one plain-language conversation and automatically fills every field on the ACORD 130 Workers Compensation Application, ready for broker review and e-signature. No manual rekeying, and no logins or downloads for the insured.
- What information does the ACORD 130 Workers Compensation Application ask for?
- The ACORD 130 Workers Compensation Application includes fields for Form Edition Identifier, Form Completion Date, Producer Full Name, Producer Mailing Address Line One, Producer Mailing Address Line Two, and Producer Mailing Address City Name. These are examples from the PDF; the exact questions that apply depend on the risk and coverage requested.
- How many fields does the ACORD 130 Workers Compensation Application have?
- The ACORD 130 Workers Compensation Application has 482 fillable fields across 4 pages. Bindly captures them all from a single conversation with the insured.