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Homepage ➨ Fill Out a Valid Acord 130 Template
Content Overview

Guide to Writing Acord 130

Completing the Acord 130 form is a crucial step in securing workers' compensation insurance. Accurate and thorough information will help ensure that your application is processed efficiently. Follow the steps below to fill out the form correctly.

  1. Enter the date of application in the MM/DD/YYYY format.
  2. Fill in the agency name and address.
  3. Provide the company name and the underwriter details.
  4. Complete the applicant name section along with office phone and mobile phone.
  5. Input the mailing address, including ZIP + 4 or Canadian Postal Code.
  6. Indicate the number of years in business and the SIC code.
  7. Fill in the producer name and NAICS code.
  8. Provide the CS representative information, including website name, address, office phone, and email address.
  9. Choose the business structure (e.g., sole proprietor, corporation, LLC, etc.) and fill in the corresponding phone number.
  10. Enter the credit ID number and address.
  11. Provide details for the bureau name, code, sub code, and federal employer ID number.
  12. Complete the NCCI risk ID number and any other relevant rating bureau ID or state employer registration number.
  13. Fill in the agency customer ID and the status of submission.
  14. Indicate the billing/audit information, including options like quote issue, policy, billing plan, and payment plan.
  15. For locations, provide the highest street, city, county, state, and ZIP code.
  16. Fill in the policy information, including proposed effective and expiration dates.
  17. Complete the workers compensation sections, including states insured, coverage amounts, and any additional coverages.
  18. Provide total estimated annual premium information for all states.
  19. Complete the contact information for individuals included or excluded.
  20. List any partners, officers, or relatives and their details, including remuneration and relationship.
  21. Fill in the rating information for each state, including class codes and estimated annual remuneration.
  22. Provide prior carrier information and loss history for the past five years.
  23. Describe the nature of business and operations.
  24. Answer all general information questions truthfully.
  25. Sign and date the application at the bottom, ensuring that the signature is from an authorized representative.

After completing the form, review all entries for accuracy. Ensure that all necessary attachments are included. Submit the form to your insurance agent or broker to initiate the application process.

Document Breakdown

Fact Name Description
Form Purpose The ACORD 130 form is used to apply for workers' compensation insurance.
Application Date The applicant must provide the date of application in MM/DD/YYYY format.
Contact Information Includes multiple contact fields such as office phone, mobile phone, and email address for both the applicant and agency.
State-Specific Requirements Some states have additional requirements, such as Missouri's Section 287.090 RSMo for exclusions.
Coverage Information The form details various coverage options, including workers' compensation and employer's liability.
Estimated Premiums Applicants must provide total estimated annual premiums and minimum premiums for all states.
Loss History Applicants must disclose loss history for the past five years, including claims and amounts paid.
Fraud Warning The form includes a warning about the consequences of submitting false information, which varies by state.

FAQ

What is the purpose of the Acord 130 form?

The Acord 130 form is used to apply for workers' compensation insurance. This document collects essential information about the applicant's business operations, including details such as the type of business, estimated payroll, and previous insurance coverage. The information provided helps insurance companies assess risk and determine appropriate premiums.

What information is required on the Acord 130 form?

The Acord 130 form requires various pieces of information, including:

  1. Applicant's name and contact details.
  2. Business structure (e.g., corporation, partnership, sole proprietor).
  3. Years in business and relevant industry codes (SIC and NAICS).
  4. Details about employees, including their roles and remuneration.
  5. Information about prior insurance coverage and loss history.

Completing the form accurately is crucial for obtaining a quote and ensuring proper coverage.

How is the estimated annual premium determined on the Acord 130 form?

The estimated annual premium is calculated based on several factors, including:

  • The type of business and associated risks.
  • The total estimated payroll for employees.
  • The classification codes that correspond to the business activities.
  • Any applicable discounts or surcharges based on the company's history and safety practices.

Insurance providers use this information to assess the overall risk and set the premium accordingly.

What should be done if there are changes in business operations after submitting the Acord 130 form?

If there are changes in business operations after submitting the Acord 130 form, it is essential to notify the insurance provider as soon as possible. Changes may include alterations in the number of employees, the nature of the work performed, or any other significant operational adjustments. Failure to report these changes can lead to coverage issues or complications during claims processing.

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Acord 130 Example

WORKERS COMPENSATION APPLICATION

DATE (MM/DD/YYYY)

 

 

 

AGENCY NAME AND ADDRESS

 

 

 

 

COMPANY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNDERWRITER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE PHONE:

 

 

 

 

 

 

 

 

 

 

MOBILE PHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (including ZIP + 4 or Canadian Postal Code)

YRS IN BUS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIC:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRODUCER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAICS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CS REPRESENTATIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WEBSITE

 

 

 

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS:

 

 

 

OFFICE PHONE

 

 

 

 

 

 

 

 

 

 

E-MAIL ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(A/C, No, Ext):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOBILE

 

 

 

 

 

 

 

 

 

 

 

 

 

SOLE PROPRIETOR

 

 

CORPORATION

 

LLC

 

 

 

 

 

TRUST

 

 

 

UNINCORPORATED

PHONE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSOCIATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBCHAPTER

 

 

 

 

 

 

 

 

 

 

 

 

 

FAX

 

 

 

 

 

 

 

 

 

 

 

 

 

PARTNERSHIP

 

 

 

JOINT VENTURE

 

 

 

OTHER:

 

 

 

(A/C, No):

 

 

 

 

 

 

 

 

 

 

 

 

 

"S" CORP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL

 

 

 

 

 

 

 

 

 

 

 

 

CREDIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID NUMBER:

 

 

 

ADDRESS:

 

 

 

 

 

 

 

 

 

 

BUREAU NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODE:

 

 

 

 

 

 

SUB CODE:

 

 

FEDERAL EMPLOYER ID NUMBER

 

 

NCCI RISK ID NUMBER

 

 

 

OTHER RATING BUREAU ID OR STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER REGISTRATION NUMBER

AGENCY CUSTOMER ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS OF SUBMISSION

 

BILLING / AUDIT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUOTE

 

 

 

ISSUE POLICY

 

BILLING PLAN

 

PAYMENT PLAN

 

 

 

 

 

 

 

 

 

 

 

 

AUDIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BOUND (Give date and/or attach copy)

 

 

AGENCY BILL

 

 

ANNUAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AT EXPIRATION

 

 

MONTHLY

 

ASSIGNED RISK (Attach ACORD 133)

 

 

DIRECT BILL

 

 

SEMI-ANNUAL

 

 

 

 

 

 

 

 

 

 

 

 

SEMI-ANNUAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUARTERLY

 

 

% DOWN:

 

 

 

 

 

 

 

QUARTERLY

 

 

 

LOCATIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOC #

HIGHEST

 

STREET, CITY, COUNTY, STATE, ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FLOOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPOSED EFF DATE

 

 

PROPOSED EXP DATE

 

 

NORMAL ANNIVERSARY RATING DATE

 

 

PARTICIPATING

 

 

 

 

RETRO PLAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-PARTICIPATING

 

 

 

 

 

 

 

 

PART 1 - WORKERS

PART 2 - EMPLOYER'S LIABILITY

 

 

 

 

 

PART 3 - OTHER

 

 

DEDUCTIBLES

 

 

 

 

AMOUNT / %

OTHER COVERAGES

 

 

 

 

 

 

 

 

 

 

(N / A in WI)

 

 

 

 

 

 

COMPENSATION (States)

 

 

 

 

 

STATES INS

 

 

 

 

 

(N / A in WI)

 

 

 

 

 

 

 

 

 

$

 

 

 

EACH ACCIDENT

 

 

 

 

 

MEDICAL

 

 

 

 

 

 

U.S.L. & H.

 

 

MANAGED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CARE OPTION

 

 

 

 

 

 

$

 

 

 

DISEASE-POLICY LIMIT

 

 

 

 

 

 

 

 

 

 

INDEMNITY

 

 

 

 

 

 

 

 

VOLUNTARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMP

 

 

 

 

 

 

 

 

 

$

 

 

 

DISEASE-EACH EMPLOYEE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOREIGN COV

 

 

 

DIVIDEND PLAN/SAFETY GROUP

 

ADDITIONAL COMPANY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES

TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES

TOTAL MINIMUM PREMIUM ALL STATES

TOTAL DEPOSIT PREMIUM ALL STATES

$

$

$

 

 

 

CONTACT INFORMATION

TYPE

NAME

OFFICE PHONE

MOBILE PHONE

E-MAIL

 

 

 

 

 

INSPECTION

 

 

 

 

 

 

 

 

 

ACCTNG

 

 

 

 

RECORD

 

 

 

 

CLAIMS

 

 

 

 

INFO

 

 

 

 

INDIVIDUALS INCLUDED / EXCLUDED

PARTNERS, OFFICERS, RELATIVES ( Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.

STATE

LOC #

NAME

DATE OF BIRTH

TITLE/

OWNER-

DUTIES

INC/EXC

CLASS CODE

REMUNERATION/PAYROLL

RELATIONSHIP

SHIP %

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACORD 130 (2013/01)

Page 1 of 4

© 1980-2013 ACORD CORPORATION. All rights reserved.

 

The ACORD name and logo are registered marks of ACORD

STATE RATING SHEET #

 

OF

 

SHEETS

AGENCY CUSTOMER ID:

STATE RATING WORKSHEET

FOR MULTIPLE STATES, ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM RATING INFORMATION - STATE:

LOC # CLASS CODE

DESCR

CODE

CATEGORIES, DUTIES, CLASSIFICATIONS

# EMPLOYEES

FULL PART

TIME TIME

SIC

NAICS

ESTIMATED ANNUAL

REMUNERATION/

PAYROLL

ESTIMATED

RATE ANNUAL MANUAL PREMIUM

PREMIUM

STATE:

FACTOR

FACTORED PREMIUM

 

FACTOR

FACTORED PREMIUM

TOTAL

N / A

$

 

 

$

INCREASED LIMITS

 

$

SCHEDULE RATING *

 

$

DEDUCTIBLE *

 

$

CCPAP

 

$

 

 

$

STANDARD PREMIUM

 

$

EXPERIENCE OR MERIT

 

$

PREMIUM DISCOUNT

 

$

MODIFICATION

 

 

 

 

$

EXPENSE CONSTANT

N / A

$

ASSIGNED RISK SURCHARGE *

 

$

TAXES / ASSESSMENTS *

N / A

$

ARAP *

 

$

 

 

$

* N / A in Wisconsin

 

 

 

 

 

TOTAL ESTIMATED ANNUAL PREMIUM

$

MINIMUM PREMIUM

$

DEPOSIT PREMIUM

$

REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

 

 

ACORD 130 (2013/01)

Page 2 of 4

PRIOR CARRIER INFORMATION / LOSS HISTORY

AGENCY CUSTOMER ID:

PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS

 

 

 

LOSS RUN ATTACHED

 

YEAR

CARRIER & POLICY NUMBER

ANNUAL PREMIUM

MOD

# CLAIMS

AMOUNT PAID

RESERVE

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

 

POL #:

 

 

 

 

 

 

 

CO:

 

 

 

 

 

 

POL #:

NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS

GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING - RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT; CONTRACTOR - TYPE OF WORK, SUB-CONTRACTS; MERCANTILE - MERCHANDISE, CUSTOMERS, DELIVERIES; SERVICE - TYPE, LOCATION; FARM - ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS.

GENERAL INFORMATION

EXPLAIN ALL "YES" RESPONSES

1.DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT?

2.DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)

3.ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?

4.ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?

5.IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?

6.ARE SUB-CONTRACTORS USED? (If "YES", give % of work subcontracted)

7.ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE? (If "YES", payroll for this work must be included in the State Rating Worksheet on Page 2)

8.IS A WRITTEN SAFETY PROGRAM IN OPERATION?

9.ANY GROUP TRANSPORTATION PROVIDED?

10.ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?

11.ANY SEASONAL EMPLOYEES?

12.IS THERE ANY VOLUNTEER OR DONATED LABOR? (If "YES", please specify)

13.ANY EMPLOYEES WITH PHYSICAL HANDICAPS?

14.DO EMPLOYEES TRAVEL OUT OF STATE? (If "YES", indicate state(s) of travel and frequency)

15.ARE ATHLETIC TEAMS SPONSORED?

Y / N

ACORD 130 (2013/01)

Page 3 of 4
(Applicant's Initials):

GENERAL INFORMATION (continued)

AGENCY CUSTOMER ID:

EXPLAIN ALL "YES" RESPONSES

16.ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?

17.ANY OTHER INSURANCE WITH THIS INSURER?

18.ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED IN THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)

19.ARE EMPLOYEE HEALTH PLANS PROVIDED?

20.DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES?

21.DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

22.DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If "YES", # of Employees:

23.ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE (5) YEARS? (If "YES", please specify)

24.ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITY NAME(S) AND POLICY NUMBER(S).

Y / N

SIGNATURE

Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)

PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.

(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.)

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).

Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

Applicable in Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company, Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).

Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Applicable in Utah: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

APPLICANT'S SIGNATURE (Must be Officer, Owner or Partner)

DATE

PRODUCER'S SIGNATURE

NATIONAL PRODUCER NUMBER

ACORD 130 (2013/01)

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