ACORD 134 – Workers Compensation Application Supplement – Multi State Rating Sheet
ACORD’s Workers Compensation Application Supplement should be used when more space is required to record rating information for multiple states.
- Agency Agency’s name and address.
- 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
- Company Name of the applicable insurance company. Use the actual name of the company within the group in which you wish to have the policy issued. Do not use group names.
- Underwriter Field used to direct the application to a specific company underwriter by name.
- Applicant Name “Full name of the applicant as it appears 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, the one intended to receive these rights and responsibilities is named first.) If joint ownership is claimed, the name used may include both names (e.g., John and Mary Smith).
Phrases such as “”et al.”” or “”As their interests may appear”” are not legal entities and therefore unacceptable.”
- E-Mail Address Provide the e-mail address for the applicant, if applicable.
- Information must be entered by state.
- State State abbreviation for the associated location.
- Factor Column The Factor column is used to calculate the total estimated annual premium. Agents completing the rating process should fill out this section of the application.
- Factored Premium Column The Factored Premium column is used to calculate the total estimated annual premium. Agents completing the rating process should fill out this section of the application.
- Total Add the amounts for each class to obtain the total estimated pre-modified premium.
- Increased Limits Enter the factor and modified total premium if limits other than the standard limits for Part 2 Employers Liability are requested.
- Deductible If a state deductible option is available and chosen, enter the deductible factor and the modified total premium.
- Experience or Merit Modification If the applicant is subject to experience or merit rating, enter the modification factor and the modified total premium. Generally the business has to have been in operation 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 or merit rating. If more than one modification factor applies to the applicant, explain in the Remarks section. Attach the most recent experience or merit rating data sheet.
- Loss Constant If a Loss Constant is applicable due to low premium levels enter the flat amount as per the rating manuals.
- Assigned Risk Surcharge Applicable only to assigned risk accounts. A state specific surcharge may apply for placement of business into an assigned risk pool.
- ARAP Assigned Risk Adjustment Program – A state specific adjustment for Assigned Risk policies.
- Schedule Rating If schedule rating applies, enter the factor and the modified total premium.
- CCPAP Contracting Class Premium Adjustment Program – Not applicable in all states. If CCPAP applies, enter the factor and modified premium.
- Standard Premium Total premium before applying premium discount.
- Premium Discount If a Premium discount is applicable due to large premium levels, enter the discount rate and the modified total premium.
- Expense Constant Enter the flat amount of the expense constant as applicable per state rating manual.
- Taxes/Assessments Enter any applicable state taxes or assessments.
- Optional Lines (Blank Spaces) If any optional factors, charges or credits are required or applicable, enter the option title, factor (if applicable) and adjustment amounts in these available spaces.
- Estimated Annual Premium Amount resulting from applying all modifications, discounts, taxes and other rating criteria to the estimated pre-modified premium.
TOTAL ESTIMATED ANNUAL PREMIUM ALL STATE
Total Estimated Annual Premium – All States Amount resulting from applying all modifications, discounts, taxes and other rating criteria to the total estimated pre-modified premium for all states.
Remarks Use this space for any additional comments or remarks.