Workers Compensation Application



The Workers Compensation Application is needed for almost every business with employees. Last time I looked - and it has been a while - the magic number of employees that required you to carry workers compensation insurance was 4. Your state or industry may be different.

The Workers Comp app is self contained and does not require the ACORD 125.

Basic Workers Comp Application forms

ACORD 130 - Workers Compensation App - all states except Florida



Workers Compensation Application page 1

Workes Comp App page 2

The Worker Compensation Application provides for workers' compensation, employer's liability, and voluntary compensation coverages.

ACORD 134 - Workers Comp App Supplement - Multi-state rating worksheetFlorida

Workers Compensation worksheet



The Workers Compensation Application Supplement should be used when more space is required to record rating information for multiple states.

ACORD 63 - Fraud (Some states require a state specific form)

General Fraud Statement



You should have your insured sign the General Fraud Statement as a matter of course.

Some states have specific wording for their Fraud Forms. You should use any state specific form that applies instead of the general form.

ACORD 64US Workers Compensation- Terrorism Coverage Rejection

Terrorism Rejection forms for Workers Compensation application



The workers Compensation Application allow your insured to reject Terrorism Coverage. Use the ACORD 60US if your insured wishes to reject Terrorism Coverage.

The following states have additional forms...

Alaska
Colorado
Connecticut
Delaware
Florida
Georgia
Kansas
Michigan
New Jersey
New Mexico
New York
North Carolina
Pennsylvannia
Tennessee
Virginia
Wisconsin

For Workers Compensation Risks which can not be written voluntarily, you need to use the Assigned Risk Application for these.

ACORD 133 Workers Compensation Insurance Plan Assigned Risk Section - Except for the following states...

Florida
Michigan
Montana
New Jersey
North Carolina
Tennessee
Wisconsin






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Return to the "Which ACORD forms to Use" page from the Workers Compensation Application page.