Acord 130 Fl. Its content is considered a part of and is incorporated by reference into any workers compensation and employers liability insurance policy issued by the FWCJUA. ACORD 130 201309 REMARKS ACORD 101 Additional Remarks Schedule may be attached if more space is required STATE RATING SHEET OF SHEETS AGENCY CUSTOMER ID.
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. This document supplements your ACORD 130 FL Application for workers compensation and employers liability insurance to be issued by the FWCJUA. Sep 09 2020 c Each employer applying for workers compensation coverage in the Florida Workers Compensation Joint Underwriting Association FWCJUA shall use Form ACORD 130 FL 201907 unless the FWCJUA files and receives approval by the Office of Insurance Regulation to use a different application form in accordance with paragraph 1 b.
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.
ACORD 130 201301 REMARKS ACORD 101 Additional Remarks Schedule may be attached if more space is required STATE RATING SHEET OF SHEETS AGENCY CUSTOMER ID. This form must be attached to an acord this form along with an acord 130 workers compensation application constitute an application for the acord name and logo are registered marks of acord. Florida Acord 130 Workers Compensation Application The State specific workers compensation application for Florida Employers. Florida statutes state that i will remain liable and will reimburse the carrier for any workers compensation benefits paid to this omitted employee.
