Acord 130 Ca. ACORD 130 with Images of the Policy Data Entry Sections. PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS.
Acord 130 201705 Applicable in OR. Page 2 of 4 FOR MULTIPLE STATES ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM STATE RATING WORKSHEET N A in Wisconsin N A N A N A MODIFICATION. Specific ACORD 38s are available for applicants in these states Applicants Initials.
Not applicable in AZ CA DE KS MA MN ND NY OR VA or WV.
Acord 130 Tutorial for the Work Comp Commercial Lines Application. You can refer to the following sample of the ACORD 130 Workers Compensation Application form to determine the corresponding AMS360 fields. Page 2 of 4 FOR MULTIPLE STATES ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM STATE RATING WORKSHEET N A in Wisconsin N A N A N A MODIFICATION. ANY PRIOR COVERAGE DECLINED CANCELLED NON-RENEWED IN THE LAST THREE 3 YEARS.
