ACORD 133 Instructions




ACORD 133 (2004/11) Workers Compensation Insurance Plan Assigned Risk Section

The Workers Compensation Insurance Plan Assigned Risk Section (ACORD 133) is designed to be used in conjunction with the ACORD Workers Compensation Application (ACORD 130). These two forms collect the data necessary for submitting assigned risk business.


Please answer all questions thoroughly. Any omission may result in delay or denial of coverage. Where space restricts a complete answer, attach answer on a separate sheet of paper. These applications do not provide coverage.
Refer to the National Council on Compensation Insurance Inc. (NCCI) WCIP State Instruction pages for state specific instructions on completing the ACORD 133 and ACORD 130 for WCIP business.


All questions regarding the preparation of this form should be referred to the NCCI Service Center shown on the state instruction pages.


APPLICANT INFORMATION SECTION

Date Enter date of application.


Applicant Name Enter the complete legal name of the employer. Provide all applicable D.B.A.'s (Doing business as). If more than one named insured, please submit appropriate ERM 14 form(s) "Confidential Request for Information." Contact NCCI for this form.


Proposed Effective Date "Enter the proposed policy effective date. Such requested effective date shall be the later of the following options:
1. 12:01 A.M. on the date following the receipt by the Plan Administrator of a complete and eligible application,
2. the date of expiration of existing coverage, or
3. a date the application requested.


SUPPLEMENTAL INFORMATION

Payroll Office Name and Address List the company name, physical address and telephone number where payroll records are maintained. A P.O. box address only is not acceptable.


State Developing Highest Payroll Enter the state which generates the highest payroll and follow all specific instructions for this state.

1. Prior Coverage question If there was no prior coverage, indicate why by checking the appropriate box for either new business, self insured (independent or group), or insufficient number of employees.

2. Premium Due or in Dispute question Details of any outstanding obligations must be furnished in the available space, in the Remarks Section or on an attached separate piece of paper.

3. Year Applicant's Business Began List the month, day and year the current owners purchased or started the business.


4. Name/Ownership Over 5 Years question A signed ERM-14 form "Confidential Request for Information," must accompany the application if a name or ownership change has occurred over the past five years, and has not already been reported. Contact NCCI for this form.

5. Related Entities question List all related entities, providing a detailed explanation of the type of relationship (e.g., management, ownership, etc.).

6. Do you lease workers from a labor contractor? Refer to the WCIP state instruction sheet for state requirements.

7. Do you lease workers to a client company? Refer to the WCIP state instruction sheet for state requirements.


8. Are you seeking to cover leased workers? Refer to the WCIP state instruction sheet for state requirements.


9. Do you provide temporary labor services to other employers? If yes, give a complete description of type of services provided (e.g., type of work being performed, duration, etc.) and a copy of the service contract, if available.

10. Do you have a franchise or licensing agreement? Provide details of agreement including franchiser's name and address.

11. Do trucking classifications apply? If yes, complete questions 12, 13, and 14.


12. Base Terminal question List the complete address for each base terminal which is used by the drivers to load, unload, and/or transfer freight on a regular basis.


13. Driver's State of Majority Driving Time question If the state of majority driving time can be established for each driver through verifiable logs or records, list the state for each driver in the appropriate section of question 14.


14. Drivers Listing "The drivers listing should include the following for each driver:
* driver name
* base terminal (if applicable)
* state of majority driving time (if applicable)
* state of residence.


INSURANCE COMPANIES WHO HAVE OFFERED/REFUSED INSURANCE

1. Have you received any offers of voluntary coverage? An offer of voluntary coverage will affect an applicant's eligibility for Plan coverage; therefore voluntary offers of coverage must be fully and completely described.


2. Refusing Insurance Companies information. Refer to the state instructions for requirements regarding the number of refusals needed before an applicant is eligible for the state's WCIP coverage. Refusal must come from non-affiliated insurers who are licensed and actively writing workers compensation insurance in the state of application. The employer and/or its representative must retain in file the refusing carrier's name, contact person, address, phone number and date of refusal.


REMARKS

Use this section to provide any additional information required for underwriting or rating.


PREMIUM PAYMENT

  • Electronic Funds Transfer (EFT) - Submit the complete nine (9) digit ABA number or bank routing number, and the complete account number in the boxes provided. Indicate the premium payment amount (in whole dollars) which NCCI, Inc. is authorized to deduct from the account. The funds may be drawn on an agency or applicant's account. For this option, a commercial account must be used.
  • Coverage cannot be bound if the required deposit premium is not received. Please refer to the appropriate WCIP instructions for deposit premium requirements and premium calculation guidelines.
  • Mail-In Check - Make check payable to NCCI, Inc. or other Plan Administrator, if applicable. The check may be in the form of an agency check, applicant's check, cashier's check, certified check, draft, money order, or finance company check.
  • Coverage cannot be bound if the required deposit premium is not received. Please refer to the appropriate WCIP instructions for deposit premium requirements and premium calculation guidelines.


APPLICANT'S STATEMENT

  • The Loss Sensitive Rating Plan acknowledgement applies only in those jurisdictions where the program has been approved for use.
  • Reminder: Both the 130 and 133 applications must be signed by the insured and the producer.
  • Applicant's Name and Title Indicate the applicant's name and title.
  • Date Indicate the date application signed.
  • Signature This application must be signed by a sole proprietor, partner, corporate owner or officer. If a person other than any of these has signed the application (e.g., spouse, trustee, general manager), attach a copy of the power of attorney. With the signature, provide the signer's name, title and signature date.


PRODUCER'S CERTIFICATION

  • Agency FEIN Enter the Agency FEIN (Federal Employer Identification Number).
  • Agency Phone Number Enter the Agency phone number.
  • Agency Fax Number Enter the Agency fax number.
  • Resident License Number Enter the Agency resident license number.
  • Expiration Date Enter the Agency resident license expiration date.
  • Non-Resident License Number Enter the Agency non-resident license number.
  • Expiration Date Enter the Agency non-resident license expiration date.
  • Producer Name Enter the producer's name.
  • Date Enter the date.
  • Producer Signature Producer must sign this form.
  • E-Mail Address Enter the Agency e-mail address.


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