The generic Workers Compensation Application, ACORD 130,
cannot be used in Florida.
The ACORD Florida Workers Compensation Application is a Commercial
Lines
application that is self-contained, that is, it does not require the completion
of the
Applicant Information Section (ACORD 125). As a result, the entire Identification
section
should be completed.
The Florida Workers Compensation Application provides for Workers
Compensation,
Employer's Liability, and Voluntary Compensation coverages.
The Policy Information and Rating Information sections follow
the Workers Compensation
rules as published by the National Council on Compensation Insurance (NCCI).
Other
plans may be used with this form as well. Please refer to the NCCI manual for
coverage
definitions.
ACORD and NCCI cooperated with the Florida Division of Insurance
in the development and promulgation of the Florida Workers Compensation Forms.
These forms are a result of the passing of Section 3 of CS/HB 3809 (Ch. 90-201)
Laws of Florida which was signed into effect July 1, 1990. The Florida DOI has
also passed recent regulations relating to these forms.
Questions regarding the completion of this form that are not
answered by the guidelines below should be directed to he Florida Division of
Insurance, Workers' Compensation Section. Phone: 850-413-5368.
The application requirement applies to new and renewal policies.
Unless the insurance
company has been changed, it is unnecessary to file an application on renewals
after filing
them the first year. This includes policies written by out-of- state agents
that have covered
Florida exposure.
IDENTIFICATION
Date
Month/day/year (MM/DD/YYYY) on which the form is completed.
Producer
Producer's name, address and telephone number.
Phone Number
Producer's phone number, include area code and extension.
Fax Number
Producer's phone number, include area code.
License #
License number of the producer.
Code
Identification code assigned to your agency or brokerage firm by the insurance
company
receiving this form.
Subcode
If your agency uses a sub-code identification system with the company, enter
the appropriate
code.
Company
Name of the applicable insurance company. Do not use group names; use the actual
name of
the company within the group in which you wish to have the policy issued.
Underwriter
This field is used to direct the application to a specific company underwriter
by name.
Applicant Name
Enter the full name of the applicant as it should appear on the policy. (The
First Named
Insured is given certain rights and responsibilities by the policy contract
language. If more
than one insured is named, be sure the one intended to receive these rights
and
responsibilities is named first.) If joint ownership, the name used may include
both names
(e.g., John and Mary Smith). Wording such as "et al" or "as their
interests may appear" is
not acceptable as the name of the insured. These phrases are not legal entities.
Include the names of all dba's and their subsidiaries.
Mailing Address
Address at which the First Named Insured is to receive all mail.
Years in Business
Number of years the applicant has been in business. This is important. It helps
the
underwriter determine the expertise and business success of the applicant.
SIC
Enter the appropriate Standard Industry Class code assigned to the type of business
engaged
in (if known).
Form of Business Organization
Place an "X" in the box to identify the applicant as an Individual,
Partnership, Corporation,
Subchapter "S" Corporation or Other. If Other, provide a description.
Example: Professional
Association. If there is more than one Named Insured, list each Named Insured
along with
its form of organization (e.g., The Green Thumb Co., a corporation, John Jones
and Bill
Smith, a partnership; or "A joint venture composed of ABC Contracting Inc.
and XYZ
Contracting Inc."). If the list is too long for the space provided, attach
a separate list.
Federal Employer ID Number
The FEIN is a number assigned by the IRS that specifically identifies the applicant.
This
number is required in most states before a policy can be issued. A separate
FEIN may apply
to each entity named as an insured. For individuals, use Social Security number.
NCCI I.D. Number
A nine-digit number assigned to the applicant by the National Council on Compensation
Insurance (NCCI). The NCCI is a rating bureau that operates in most states and
also
provides interstate experience rating for risks that operate in more than one
state. This
identification number is required in most states before a policy can be issued.
It will also
help insure timely and accurate calculation of experience modifications.
Other Rating Bureau I.D. Number
If the applicant is subject to experience rating in an independent bureau state,
that state's
rating bureau may assign a separate identification number. If so, enter that
number here.
STATUS OF SUBMISSION
Use the Quote/Issue Policy/Bound boxes to indicate whether
the response to this application from
the company is expected to be a quote or an issued policy.
BILLING/AUDIT INFORMATION
Billing Plan
Indicate whether the agency or the company (direct) will bill the insured or
other payer for
the policy.
Payment Plan
Indicate the plan to be used to pay the company for the policy. For the Other
option, use
the company's specific designation for the plan being used. Example: Bi-monthly
or 40-30-
30.
% Down
For bound policies, list the percentage of the total estimated annual premium
that has been
(or will be) received as a down payment.
Audit Record
Use the boxes provided to indicate the frequency with which audits should be
undertaken
for this policy.
LOCATIONS
List all usual work places of the applicant. Provide the physical
address, not post office boxes..
POLICY INFORMATION
Proposed Eff. Date
The Effective Date is the date on which the terms and conditions of the policy
will
commence.
Proposed Exp. Date
The Expiration Date is the date on which the terms and conditions of the policy
will expire.
The normal policy period (effective date to expiration date)
is one year. However, a policy
may be issued for any length of time up to a maximum of three years. Certain
rules and
endorsements must be used if the policy is written for more than one year. It
may be
necessary to use Effective and Expiration Dates that do not indicate a one year
term to gain
concurrence with other policies.
Normal Anniversary Rating Date
Normally, the rates used are those in effect on the effective date of the policy.
NCCI
Manual rules require the rates to apply for a period of one year. If a policy
is canceled or
short-termed, the rating bureau requires the original effective date to be considered
the
Normal Anniversary Rating Date for both rates and experience modifications.
This is a
temporary situation that will last until the next renewal, whereupon the new
policy
effective date will again determine the rates. The purpose of this rule is to
prevent wholesale
cancellations by insureds and companies to take advantage of rate and/or rule
changes. For
canceled or short-termed polices, enter the original effective date.
Participating/Non-Participating
A Participating policy may result in reduced premiums through the payment of
policyholder
dividends declared by the insurer. Some policyholder dividends are based on
actual
experience of the applicant. If such a program is available through the company
in the
covered state, indicate whether the policy is to be on a Participating or Non-Participating
basis. Check with your company on the availability of plans.
Retro Plan
Retrospective rating plans permit the adjustment of the final premium based
on the actual
premiums and losses of the applicant, subject to the plan's minimum and maximum
premium limits. One to three year plans may be available. Check with your company
on the
availability of plans.
Part 1 (States)
Indicate the states in which Part 1 will apply. Part 1 refers to the Workers
Compensation
Law and/or Occupational Disease Law in states where the applicant has operations.
Part 2 - Employers Liability
Enter the requested limits for Part 2 of the policy (Employers Liability Insurance).
The
standard limits of liability under Part 2 are: Bodily Injury By Accident: $100,000-each
accident/Bodily Injury by Disease: $500,000-policy limit/Bodily Injury by Disease:
$100,000-
each employee. Be sure to express limits with full dollar amount (all zeros
shown) on the
application.
Part 3 - Other States Ins
Provide a list of all other states where the insured will be operating.
Other Coverages
Use this space to request optional United States Longshoremen's & Harbor
Worker's
(U.S.L. & H.) Coverage and Voluntary Compensation Coverages. Exposures for
these
optional coverages as well as additional coverages should be described in the
Specify
Additional Coverages/Endorsements section.
Dividend Plan or Safety Group
Identify the specific plan or the safety group of which the applicant is a member.
This field
is related to the participating plan. Check with your company on the availability
of plans.
Additional Company and State Information
If Part 3 - Other States Insurance - is to be written, states falling under
Part 3 need to be
listed in this section. State abbreviations should be listed preceeded by the
words Part 3 -
Other States Insurance - Included. Any additional company or state specific
information
should also be listed in this section.
Deductible
Made available at the written request of the employer, in the amount of $500,
$1,000,
$1,500, $2,000 and $2,500 per claim. See the Florida Benefits Deductible And
Coinsurance
Programs for more details.
Coinsurance Limit
Made available at the written request of the employer. The carrier will pay
80 percent and
the employer will pay 20 percent per claim of the benefits due to an employee
for an injury
compensable under Florida Benefits Deductible And Coinsurance Programs.
RATING INFORMATION
Location Number
The location number for each entry which corresponds to the locations listed
in the
Locations section above.
Class Code
The Classification Code which best describes the business of the applicant.
It is important
to remember that it is the business of the employer, not the individual employees,
that is
being classified. Consult the proper rating manual to determine the code. Rating
bureaus
may exercise control over classification assignment.
Company Use
Leave this space blank. The insurer may use this space for special computer
codes, to
identify the applicable class description wording.
Categories, Duties, Classifications
A single class code may include several related descriptions of activities/operations.
Therefore, it is extremely important to enter the specific classification description
or, at the
very least, a brief statement regarding the duties of the employees. Enter as
much
information as necessary to avoid misclassifying the operations.
No. of Employees
Indicate the Number of Employees to whom the classification applies. The average
number
is sufficient when the total number fluctuates during the year. Underwriters
use this number
to determine if the payroll estimates appear adequate.
Actual Remuneration Past 12 Months
Indicate the remuneration (payroll) for the previous 12 months for the appropriate
class.
Remember, payroll means money or substitutes for money, such as the value of
meals or
lodging if provided. Accurate payroll estimates help to avoid additional premium
at the
time of audit.
Estimated Remuneration for Next Policy Period
The total estimated payroll for the period between the proposed effective date
and proposed
expiration date.
Rate
Enter the manual Rate for the classification from the appropriate state manual.
Estimated Annual Premium
The rate is applied (multiplied) to every $100 of remuneration (payroll) and
the result is the
Estimated Annual Premium for this classification.
Total
Add the amounts for each class to obtain the Total estimated pre-modified premium.
Experience Modification
Enter the Experience Modification factor in this space if the applicant is subject
to
experience rating. Generally, the business has to have been operating for at
least two years
under present ownership and the premium must meet or exceed a level which is
established
by the state to qualify for experience rating. If more than one modification
factor applies to
the applicant, explain the details in the Remarks section. Attach the most recent
experience rating data sheet if you have a copy.
Modified Premium
Enter the amount resulting from multiplying the Total estimated pre-modified
premium by
the Experience Modification factor.
Premium Discount
If a Premium Discount is applicable, enter the total dollar amount to be deducted
from the
modified premium. This generally applies only if the policy premium exceeds
$5,000. Refer
to the state manual.
Expense Constant
Enter the applicable charge for the state Expense Constant. This charge is no
longer limited
only to small accounts where it was intended to recover issuing and servicing
costs.
Total Estimated Annual Premium
Enter the Total Estimated Annual Premium resulting from applying all modifications,
discounts, and other rating criteria to the Total estimated pre-modified premium.
Minimum Premium
The Minimum Premiums are found on state rate sheets opposite the class code;
they apply
by policy. If two or more classifications with different Minimum Premiums are
included on
one policy, the highest usually applies. Please check the appropriate rate manual.
Deposit Premium
Enter the dollar amount due the insurer at inception.
Specify Additional Coverages/Endorsements
Use this area to explain the applicant's exposures and payroll for any other
coverage
requested, including U.S.L. & H. and Voluntary Compensation.
INDIVIDUALS INCLUDED/EXCLUDED
Sole proprietors and a maximum of three partners or corporate
officers may elect to be exempted
from coverage if they are actively engaged in the construction industry. For
any clarification of this
subject you should contact the Bureau of Compliance, at (904) 488-2713. Those
persons with
exemptions and inclusions signed and approved prior to enactment of the law
signed on January 25, 1991, should review their status and take appropriate
actions to reject or continue coverage.
Certain other positions within an organization, such as sole
proprietors and partners, may not be
covered by the applicable Workers Compensation Law, but they may be permitted
to elect to be
brought under it. Conversely, executive officers of corporations are generally
considered employees,
but may have the option to elect to be excluded from coverage. Refer to the
NCCI or applicable
state Workers Compensation manual for the details. Since the inclusion or exclusion
affects
coverage and premium, this section must be fully completed.
Name
Enter the name of the partner, executive officer or relative for purposes of
indicating
whether or not the individual is to be covered by the policy.
Date of Birth
This individual's birth date.
Social Security #
The social security number of each person. Disclosure of this infomation is
voluntary. See instructions on the form.
Title/Relationship
Provide either the individual's title within the organization or relationship
to the
organization's owners.
Ownership %
Indicate the percentage of ownership the individual has in the organization,
if applicable.
Duties
Briefly identify the duties of the individual. This will help to ascertain the
proper
classification.
Inc/Exc
Indicate if the individual is to be Included or Excluded under the policies
coverages.
Class Code
Enter the Class Code for individuals to be included based on the duties described
above.
Remuneration
Provide the estimated annual Remuneration for individuals to be included. Minimum
or
maximum remunerations may be applicable based on the state law. (Be sure to
enter the
class code and remuneration in the Rating Information section of the application
for all
included individuals).
PRIOR CARRIER INFORMATION/LOSS HISTORY
Either this section should be completed or a loss history report
should be attached covering
the last five years. If a loss history report is attached, enter "See Attached
Report" in the
first Carrier & Policy Number section.
Year
Enter the Year or policy period. The most recent policy period should be listed
first.
Carrier & Policy Number
Provide the carrier's name and policy number for the corresponding policy.
Actual Audited Premium
The acutal audited premium for the corresponding policy.
Mod.
If the risk was subject to experience rating, enter the Experience Modification
in this
column for the corresponding policy.
# Claims
Enter the total number of Claims for the corresponding policy term.
Amount Paid
This is the total dollar amount actually paid for all open or closed claims.
Reserve
Enter the amount in Reserve for any open claims, along with the valuation date
of the
reserves. Estimates are acceptable; enter zero if none.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
This section is designed to inform the underwriter of what
business each applicant performs and the
way it is conducted by premises. Operations which may not be apparent in a general
description of
operations may be segmented by location. Example: location #1 may be the general
offices while
location #2 may be the warehouse. The section should be completed in enough
detail to enable the underwriter to understand and classify each operation.
Do not use the classification phraseology from the Commercial Lines Manual or
Workers Compensation Manual. They do not provide adequate detail. Example: a
manufacturer of pulley wheels used in sewing machines should be described as
such and not as "Metal Goods Mfg. N.O.C."
If the applicant is a manufacturer, describe the:
EMPLOYEES
List all the names of the employees on the payroll. If the
company has more than four employees,
an "X" must be placed in the box labeled "Check if a list of
additional employee names is attached".
GENERAL INFORMATION
Use the Remarks section to provide additional information for
any questions answered with a "Yes"
response.
1. Does applicant own, operate or lease aircraft/watercraft?
Describe any Aircraft exposure with the exception of commercially scheduled
flights. Name
any employee who is a licensed pilot and explain his or her duties and the type
of license
held. Describe any Watercraft which is owned, leased, or operated, and explain
its use.
2. Do operations involve storing, treating discharging,
applying, disposing,
or transporting of hazardous material? (e.g. landfill, asbestos, wastes, fuel
tanks, etc.)
Explain the exposure and the precautionary measures implemented to handle hazardous
materials. The exposures would include: flammable, explosives, radioactivity,
caustics, or
fumes and their storing, disposing, or transporting, or any other material with
a known
occupational disease exposure.
3. Any work performed underground or above 15 feet?
Provide the frequency and explain the nature of such work, and the number of
people
involved.
4. Any work performed on barges, vessels, docks, bridge
over water?
Describe any work on Barges, Vessels or Docks and indicate the location, frequency,
and
number of people involved.
5. Is applicant engaged in any other type of business?
List all other businesses and identify the carrier for that business's workers
compensation
coverage.
6. Are sub-contractors and/or independent contractors
used?
Explain the nature and frequency of any subcontracted work. Are Certificates
of Insurance
required?
7. Any work sublet without certificates of ins.?
Describe the nature and frequency of the work subcontracted and indicate if
the
classifications and remuneration for such work have been included in the Rating
Information section.
8. Is a formal safety program in operation?
Describe the safety program. Does it involve meetings, classes, incentives?
9. Any group transportation provided?
Is a van pool program in effect? Does the employer shuttle employees to job
sites? What type
of conveyance is used? How many employees are transported? How often? Over what
distance? Provide details.
10. Any employees under 16 or over 50 years of age?
If Yes, specify the number of employees in each category and the duties they
perform.
11. Any part time or seasonal employees?
How many employees? How many hours do they work? At what time of the year are
they
employed? What are their duties?
12. Is there any volunteer or donated labor?
Explain the circumstances under which volunteer labor is used and the nature
of the work.
13. Any employees with physical handicaps?
Describe the nature of the work and explain the circumstances under which physically
handicapped workers are employed. Indicate the number of employees and the type
of
handicaps. Is the applicant involved in a special community program for handicapped
people? If eligible, has the employee been registered in a second injury fund?
14. Do employees travel out of state?
Describe the nature of the travel and indicate the number of employees, frequency
and
mode of transportation.
15. Are athletic teams sponsored?
Describe the nature of the athletic activities and indicate the number of employees
involved
(if any). Indicate whether the applicant provides an accident and health policy
to cover
athletic activities. This may include company, school, or community teams or
leagues.
Example: Little League.
16. Are physicals required after offers of employment
are made?
Are all employees required to undergo a physical examination after they have
been made an
offer for employment? Describe the extent of the physical examination and indicate
which
applicants are required to take them.
17. Any other insurance with this insurer?
If other insurance policies of any kind are in force with this insurer, identify
the coverages,
policy numbers, and terms. It may also be desirable to note other submissions
for this
account that are under consideration.
18. Any prior coverage declined/canceled/non-renewed
(last 3 yrs.)?
The mere fact that such action occurred is not as important as the reason for
the action.
Provide all the details.
19. Are employee health plans provided?
Indicate the carrier name and policy number for the health plan.
20. Is there a labor interchange with any other business/subsidiary?
Indicate who the interchange is being done with and their relationship to the
insured.
21. Do you lease employees to or from other employers?
For leasing employees indicate who you are leasing them to. For leased employees
indicate
who you are leasing them from and if you have a certificate of insurance from
the lessor.
22. Do any employees predominantly work at home?
Indicate who works at home and what their hours of operation are.
23. What are your estimated annual revenues?
This requires a dollar amount, not a yes/no response. Enter the estimated revenues
(income)
for the next year.
24. Is there any current or anticipated debt for unpaid
permiums owed to any previous workers' compensation provider?
This question must be answered by law.
Inspection
Enter the name and full telephone number of the individual who should be contacted
in
order for the insurer to conduct a physical inspection survey.
Accounting Records
The insurer may need to contact the applicant for audit purposes. Please provide
the name
and full telephone number of the individual responsible for such records.
Claims Information (Phone and Name)
Provide the telephone number and name of the person the insurer is to contact
regarding
any potential claims inquiries.
Remarks
Add any additional rating information, comments or other items that will assist
in the
classification and rating of this risk.
I understand that as the employer, . . .
This section spells out the conditions required of the employer
in securing Florida Workers
Compensation Coverage.
Former Names and Owners
Complete this section in accordandce with instructions on the form.
Ownership/Combinability
Complete this section in accordance with instructions on the form.
