Required Items for a Submission and Quote

Submissions

A submission is a complete ACORD 130 (dated 1995 or later) and State Fund’s Supplemental Application Form (dated 8-1-2001 or later) with signature section completed by an authorized representative as noted. State Fund’s Online Submission program is a consolidated submission form of the ACORD 130 and Supplemental Application Form (SAF) that provides the required information consistent with the ACORD 130 and SAF.

For complete instructions for using the Online Submission program please click on the following link: State Fund Online Submission Requirements

The following information is required on the ACORD 130 and Supplemental Application Form:

• ACORD 130
• Producer name
• Company name
• Applicant name
• Mailing address and Zip Code
• Locations
• “Categories classifications, duties”
• Ownership name
• Remuneration/Payroll
• Number of employees
• Federal Employer Identification Number (FEIN), State Employer Identification Number (SEIN), or Social Security Number (SSN)
• Years in business
• Class Codes(s)
• Description of Operations
• Proposed Effective date/Proposed Expiration date
• General Information section completed on the ACORD 130
• Supplemental Application Form (SAF)
• Section 1
• Section 2
• Legal entity information
• Section 4
• Section 11
• Broker access number
• Signature of authorized representative as noted

Any submission and/or Broker of Record letter not sent to a designated State Fund Office postal address, e-mail address, and/or fax number for submissions and Broker of Record letters is considered not received by State Fund. Online submissions are considered received when the broker electronically submits the application and receives the system identification number and email confirmation. Regular Broker of Record rules regarding simultaneous submissions and receive dates still apply. Once a submission is received and Broker of Record is determined, any future submissions will require a Broker of Record letter.

Submission Date

The submission date will be no earlier than four months prior to the inception date. All submissions are subject to State Fund Underwriting Rules. Submissions received on the same single business day will be considered simultaneous submissions. In the event that two or more submissions are received simultaneously, a Broker of Record letter will be required from the account.

On simultaneous submissions, the submission that includes a Broker of Record letter will be considered Broker of Record. If multiple simultaneous submissions include Broker of Record letters, State Fund will contact the employer to determine Broker of Record on the account.

Any submission received prior to four months of policy inception will be returned to broker for resubmission or submitted online will be rejected.

Quoting

To receive a quote these additional fields are required:

• Employer’s Primary Contact Name
• Class code(s)
• Ownership - title, percentage of ownership and exclusion/inclusion status
• Description of operations
• General Information sections completed on both the ACORD 130 and Supplemental Application Form.
• Licenses, Contractors State License Board or Department of Motor Vehicles, if required.
• Currently valued loss runs on the previous carrier’s letterhead (dated within 90 days of the submission date) including paid premium or payroll and total incurred and total paid losses for the four most recently completed policy years are required. Current year losses should be included in the loss runs. If losses are unavailable, a written explanation must be included with the complete submission for quoting. If previous loss information is unavailable the submission may not be eligible for participation in all State Fund programs.

Four Months to Fifteen Days Prior to Inception

If a Broker of Record Letter from another broker is received on a submission for quoting, a notification letter will be mailed to the original broker. A rescission letter from the insured for the original broker is required to obtain a quote. New broker will not receive a quote until 10 calendar days after notification.

Fifteen Days or Less Prior to Inception Date

If a Broker of Record Letter is received from another broker on a submission for quoting, a notification letter will be mailed to the original broker and the quote to the new broker is released immediately. A rescission letter from the insured for the original broker is required to be broker of record.

Expired Quotes

Once a quote has expired on a broker submission, broker will need to provide a new complete submission. Broker cannot use the expired quote to bind the account.

Broker of Record Letters

A Broker of Record Letter is a letter from the account, indicating a new broker of record for their business. The ACORD Broker of Record form (ACORD form number 36) will also be accepted. The effective date of the Broker of Record, and any notification, will be determined based on the date when State Fund receives the Broker of Record Letter. State Fund reserves the right to contact the Employer to ascertain definitive Broker of Record designation.

Broker Endorsed Group or Association

On broker submitted group or associations, the following conditions will apply:

• Broker must be the group or association endorsed broker, or managing broker, on a majority of the group or association business.
• New groups are subject to State Fund review and approval.

Note: State Compensation Insurance Fund is not a branch of the State of California.