ACORD 135NJ Instructions


ACORD 135 NJ (2009/09) rev. 08-31-2009 1 of 4

Section Name Field Name Field and/or Section Description
TITLE ACORD 135 NJ (2009/09) New Jersey Workers CompensationInsurance PlanSupplementalEmployee LeasingApplication The title of the form. ACORD 135 NJ, New Jersey Workers Compensation Insurance Plan Supplemental Employee Leasing Application, is used as a supplement to ACORD 133 NJ, when applying to the Compensation Rating and Inspection Bureau of New Jersey for workers compensation coverage for leased workers. This form was previously numbered ACORD 134 NJ.
GENERAL INFORMATION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
GENERAL INFORMATION Name of Labor Contractor Enter text: The full name of the labor contractor.
GENERAL INFORMATION Has the labor contractor operated under any other name, in any jurisdiction, in the past five (5) years? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Has the labor contractor operated under any other name, in any jurisdiction, in the past specified number of years?”.
GENERAL INFORMATION Has the labor contractor operated under any other name, in any jurisdiction, in the past five (5) years? No Check the box (if applicable): Indicates a “No” response to the question, “Has the labor contractor operated under any other name, in any jurisdiction, in the past specified number of years?”.
GENERAL INFORMATION State Name Enter text: The previous business name.
GENERAL INFORMATION Insurance Company Enter text: The name of the previous insurer.
GENERAL INFORMATION Policy # Enter identifier: The policy number of the previous coverage.
GENERAL INFORMATION From Enter date: The effective date of the prior policy.
GENERAL INFORMATION To Enter date: The expiration date of the previous coverage.
GENERAL INFORMATION Annual Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business.
GENERAL INFORMATION State Name Enter text: The previous business name.
GENERAL INFORMATION Insurance Company Enter text: The name of the previous insurer.
GENERAL INFORMATION Policy # Enter identifier: The policy number of the previous coverage.
GENERAL INFORMATION From Enter date: The effective date of the prior policy.
GENERAL INFORMATION To Enter date: The expiration date of the previous coverage.
GENERAL INFORMATION Annual Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business.
GENERAL INFORMATION Name Enter text: The remarks associated with the state.
GENERAL INFORMATION Title Enter code: The individual’s title within the organization or relationship to the organization’s owners.
GENERAL INFORMATION Percentage of Ownership Enter percentage: The percentage of ownership the individual has in the organization, if applicable.
GENERAL INFORMATION Duties Enter text: The brief description of the duties of the individual.
ACORD 135 NJ (2009/09) rev. 08-31-2009 2 of 4

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Annual Salary Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals).
GENERAL INFORMATION Name Enter text: The remarks associated with the state.
GENERAL INFORMATION Title Enter code: The individual’s title within the organization or relationship to the organization’s owners.
GENERAL INFORMATION Percentage of Ownership Enter percentage: The percentage of ownership the individual has in the organization, if applicable.
GENERAL INFORMATION Duties Enter text: The brief description of the duties of the individual.
GENERAL INFORMATION Annual Salary Enter amount: The estimated annual remuneration for individual listed. Minimum or maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the State Rating Worksheet section on Page 2 for all included individuals).
GENERAL INFORMATION Do any principal owners of the labor contractor have any ownership interest in any other business entities, in any jurisdiction? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Does any owner have an ownership interest in any other business?”.
GENERAL INFORMATION Do any principal owners of the labor contractor have any ownership interest in any other business entities, in any jurisdiction? No Check the box (if applicable): Indicates a “No” response to the question, “Does any owner have an ownership interest in any other business?”.
CLIENT INFORMATION Legal Business Name of Client Enter text: The full legal name of the client.
CLIENT INFORMATION NJTIN Enter identifier: The client’s tax identification number.
CLIENT INFORMATION FEIN Enter identifier: The client’s tax identification number.
CLIENT INFORMATION Complete Physical Address Enter text: The first line of the client’s physical address.
CLIENT INFORMATION Enter text: The second line of the client’s physical address.
CLIENT INFORMATION Enter text: The city of the client’s physical address.
CLIENT INFORMATION Enter code: The state or province code of the client’s physical address.
CLIENT INFORMATION Enter code: The postal code of the client’s physical address.
CLIENT INFORMATION Payroll Address Enter text: The first address line of the physical location.
CLIENT INFORMATION Enter text: The second address line of the physical location.
ACORD 135 NJ (2009/09) rev. 08-31-2009 3 of 4

Section Name Field Name Field and/or Section Description
CLIENT INFORMATION Enter text: The city of the physical location.
CLIENT INFORMATION Enter code: The state or province of the physical location.
CLIENT INFORMATION Enter code: The postal code of the physical location.
CLIENT INFORMATION Does the labor contractor have any outstanding premium due on any worker’s compensation policy? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Are you in debt to any insurance company for any unpaidpremium for worker’s compensation?”.
CLIENT INFORMATION Does the labor contractor have any outstanding premium due on any worker’s compensation policy? No Check the box (if applicable): Indicates a “No” response to the question, “Are you in debt to any insurance company for any unpaid premium for worker’s compensation?”.
CLIENT INFORMATION Is labor contractor duly registered with the NJ Dept of Labor and Workforce Development? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Is labor contractor duly registered with the state department of labor workforce development or similar state organization?”.
CLIENT INFORMATION Is labor contractor duly registered with the NJ Dept of Labor and Workforce Development? No Check the box (if applicable): Indicates a “No” response to the question, “Is labor contractor duly registered with the state department of labor workforce development or similar state organization?”.
LABOR CONTRACTOR/CLIENT COVERAGE Is there a written contract between the labor contractor and the client? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Is there a written contract between the labor contractor leasing employees and the client?”.
LABOR CONTRACTOR/CLIENT COVERAGE Is there a written contract between the labor contractor and the client? No Check the box (if applicable): Indicates a “No” response to the question, “Is there a written contract between the labor contractor leasing employees and the client?”.
LABOR CONTRACTOR/CLIENT COVERAGE Does client lease entire workforce from this labor contractor? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Does client lease entire workforce from this labor contractor?”.
LABOR CONTRACTOR/CLIENT COVERAGE Does client lease entire workforce from this labor contractor? No Check the box (if applicable): Indicates a “No” response to the question, “Does client lease entire workforce from this labor contractor?”.
LABOR CONTRACTOR/CLIENT COVERAGE Is client contractually affiliated with any other labor contractor? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Is client contractually affiliated with any other labor contractor?”.
Section Name Field Name Field and/or Section Description
LABOR CONTRACTOR/CLIENT COVERAGE Is client contractually affiliated with any other labor contractor? No Check the box (if applicable): Indicates a “No” response to the question, “Is client contractually affiliated with any other labor contractor?”.
LABOR CONTRACTOR/CLIENT COVERAGE Does client firm have any outstanding premium due on any worker’s compensation policy? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Is there any unpaid workers’ compensation premium due from you or any other commonly owned enterprise?”.
LABOR CONTRACTOR/CLIENT COVERAGE Does client firm have any outstanding premium due on any worker’s compensation policy? No Check the box (if applicable): Indicates a “No” response to the question, “Is there any unpaid workers’ compensation premium due from you or any other commonly owned enterprise?”.
LABOR CONTRACTOR/CLIENT COVERAGE Do any other clients of labor contractor have current coverage through NJWCIP? Yes Check the box (if applicable): Indicates a “Yes” response to the question, “Do any other clients of labor contractor have current coverage through this state’s workers compensation insurance plan?”.
LABOR CONTRACTOR/CLIENT COVERAGE Do any other clients of labor contractor have current coverage through NJWCIP? No Check the box (if applicable): Indicates a “No” response to the question, “Do any other clients of labor contractor have current coverage through this state’s workers compensation insurance plan?”.
LABOR CONTRACTOR/CLIENT COVERAGE Name of Labor Contractor Enter text: The full name of the labor contractor.
SIGNATURE Signature and Title of Officer Sign here: Accommodates the signature of the officer, owner or person authorized to legally bind the labor contractor.
SIGNATURE Enter text: The title of the officer, owner or person authorized to legally bind the labor contractor.
SIGNATURE Date Enter date: The date the form was signed.
SIGNATURE Printed Name Enter text: The full name of the officer, owner or person authorized to legally bind the labor contractor.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).