WORKERS COMPENSATION APPLICATION DATE …

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1980-2009 ACORD CORPORATION. All rights 1 of 4ACORD 130 (2009/09)MONTHLYQUARTERLYSEMI-ANNUALAT EXPIRATIONAUDIT% DOWN:QUARTERLYSEMI-ANNUALANNUALPAYMENT PLANSTATUS OF SUBMISSIONBILLING / AUDIT INFORMATIONQUOTEISSUE POLICYBOUND (Give date and/or attach copy)ASSIGNED RISK (Attach ACORD 133)DIRECT BILLAGENCY BILLBILLING PLANLOC #STREET, CITY, COUNTY, STATE, ZIP CODELOCATIONSOTHER COVERAGESVOLUNTARYCOMPFOREIGN COVMANAGEDCARE & PLAN/SAFETY GROUPADDITIONAL COMPANY INFORMATIONINDEMNITYMEDICALDEDUCTIBLES(N / A in WI)AMOUNT / %(N / A in WI)NORMAL ANNIVERSARY RATING DATENON-PARTICIPATINGPARTICIPATINGRETRO PLANPOLICY INFORMATIONPROPOSED EFF DATEPROPOSED EXP DATEPART 1 - WORKERSCOMPENSATION (States)PART 2 - EMPLOYER'S LIABILITY$$$EACH ACCIDENTDISEASE-POLICY LIMITDISEASE-EACH EMPLOYEEPART 3 - OTHERSTATES INSSPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS (Attach ACO)

time part time full. rate # employees loc # class code categories, duties, classifications sic naics estimated annual remuneration/ payroll estimated annual manual

  Applications, Compensation, Worker, Workers compensation application