Facts about the Accord 130 PDF template

Workers' compensation refers to a number of government programs that provide disability compensation to federal workers who become injured while working or acquire a disability. These programs are managed by the Department of Labor's Office of Workers' Compensation Programs, otherwise known as OWCP. The ACORD 130 form is the official application for workers' compensation.

What Is an Accord 130 PDF Form Used For?

If a person is injured while on the job, they are entitled to workers' compensation. This compensation covers the cost of their medical fees, time off from work, and any other medical-related expenses. People may also be eligible for compensation if they acquire a disability while on the job. The ACORD 130 form is the main application for compensation. It should be filled out by an applicant seeking assistance.

For corporate businesses, workers' compensation claims will generally be covered by the company's liability insurance policy. For federal workers, claims are processed through the OWCP. There are four main types of compensation:

• Wage replacement benefits to cover the time spent outside work, whether recovering or missing shifts due to doctor's appointments


• Medical treatment compensation to cover the costs of medical tests, doctor's appointments, and other medical fees


• Vocational rehabilitation compensation to cover the cost of any long-term disability or illness rehabilitation


• Other general benefits

Who Would Use an Accord 130 PDF Form?

If anyone intends to claim compensation for an injury or illness, they'll need to use this form. It's the worker's compensation application form.

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When Should an Accord 130 PDF Form Be Used?

Workers' compensation can generally be claimed if an employee suffers an injury on the job or acquires a disability. The employer is responsible for compensating the employee for time off, medical costs, and rehabilitation fees.

Any employee who wants to be compensated should use this form. It should be filled out and filed as soon as possible. For federal employees, the form should be filled with the OWCP. For individuals employed by private companies, the form should be filed with the workers' compensation board for their state.

To receive compensation, the injury or illness must be related to a person's job. Alternatively, a permanent disability must have been acquired while working at the job. If a person was disabled before being hired, or their injury or illness was not related to their work, they are not eligible for workers' compensation.

What Are the Consequences for Not Using an Accord 130 PDF Form?

The workers' compensation application form is the only way to receive workers' compensation. If you're injured or become ill on the job, you have to use this form if you intend to be compensated. Failing to do so will mean that you won't receive any compensation.

If you don't want to go the workers' compensation route, you can find out how much of your injury your health insurance company will cover. For people who don't have health insurance or are underinsured, the healthcare marketplace may be a good place to seek assistance.

How to Fill Out an Accord 130 PDF Form

• On the top portion of the form, fill out the name of the agency you're seeking compensation from. Provide all required information including the company name, your applicant name, mailing address, and email address. For federal employees, give your federal employee ID number. For other individuals, give your state employer registration number.


• Record the locations of the business. Then record information about your workers' compensation claim under "Policy Information." This includes information about the company's liability insurance, any deductibles, and the effective dates of the insurance policy.


• Give the contact information for the office that handles insurance claims. In the "Individuals Included/Excluded" section, record the individuals who are covered under the liability insurance policy for the business.


• Include information about the insurance policy and premiums under "Premium," including the deductible, any increased limits, and premium discounts. Record your total estimated premium annually, your deposit premium, and your minimum premium.


• Write any remarks about your compensation claim or the insurance policy.


• Give information about any previous carrier information or history of loss for the last five years.


• Describe the business operations.


• Under "General Information," answer all questions with a yes or no. If you have any "yes" responses, use the space underneath the question to offer an explanation. Any additional comments should go underneath the question section.


• Get the signature of the applicant and producer, the national producer number, and the date the application was filled out.

Quick Questions

How soon after the injury should the application be filed?

Do any other forms need to be filed?

What if you're not eligible for compensation?