Acord 130 Wc Application. Acord 130 201309 applicants signature must be officer owner or partner date producers signature national producer number y n agency customer id. Acord florida workers compensation application.
The Workers Compensation Application provides for workers compensation employers liability. Acord 130 200008 5. Remuneration to be included must be part of rating information section attach list of additionsexemptions if any.
Enter your official identification and contact details.
Workers compensation insurance plan assigned risk coverage. That i as an owner officer am fully authorized to sign this application on behalf of the applicant and to bind the application. Acord 130 fl 201502 page 1 of 3 locations -list all physical locations including other states whether coverage is requested or notif applicant is a professional employer organization peo employee leasing company list all client companies and their locations. If yes explain including entity names and policy numbers.
