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					                                                                                     ACORD Forms Index
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    Agency/Company Name:                                                                                      Contact Name:

    Street Address:

    City:                                                                                                     State:                                               Zip:

    Telephone:                                                                                                ACORD Account #:

    Fax:                                                                                                      E-Mail Address:

    Web Site:

                                                         All packages contain 100 forms - Please specify number of packages required
                                                                                     COUNTRYWIDE P&C FORMS
    Number      Edition   Title                                                          Quantity    Number    Edition   Title                                                              Quantity
1               2012/05   Property Loss Notice                                                      73         2009/07   Solid Fuel Questionnaire - Supplement to Residential Section

2               2012/05   Automobile Loss Notice                                                    74         2009/09   Residence Based Business - Supplement to Residential Section

3               2012/05   General Liability Notice of Occur/Claim                                   75         2010/04   Insurance Binder

4               2012/05   Workers Compensation - First Report of Injury or Illness                  76         9/93      Binder Log

5               2012/05   Aircraft Loss Notice                                                      80         2012/01   Homeowner Application

6               2009/05   Aviation Witness / Passenger Schedule                                     81         2012/02   Personal Inland Marine Application

7               2009/05   Aviation Injured Schedule                                                 82         2012/02   Watercraft Application

11              2/95      Auto Accident Information Form                                            83         2012/02   Personal Umbrella Application

12              2/95      Exchange of Information Form                                              84         2012/02   Dwelling Fire Application

13              2/95      Witness Card                                                              85         2012/03   Mobile Home Application

20              2009/12   Certificate of Aviation Liability Insurance                               88         2012/02   Personal Insurance Application - Applicant Information Section

21              2009/12   Certificate of Aircraft Insurance                                         89         2012/02   Residential Section

22              2012/04   Intermodal Interchange Certificate of Insurance                           91         2009/10   Good Student Driver Training

23              2010/05   Vehicle or Equipment Certificate of Insurance                             92         2012/03   Medical Statement

24              2009/09   Certificate of Property Insurance                                         93         2012/03   Young Driver Questionnaire

25              2010/05   Certificate of Liability Insurance                                        99         2009/02   Accidents / Convictions Schedule

26              2002/01   Policy Certification Log                                                  101        2008/01   Additional Remarks Schedule

27              2009/12   Evidence of Property Insurance                                                                 Personal Auto Application Schedule - Additional Resident and
                                                                                                    103        2012/03
                                                                                                                         Driver Information Section
28              2011/11   Evidence of Commercial Property Insurance
                                                                                                    105        2012/06   Apartment Building Supplement
29              2010/12   Evidence of Flood Insurance
                                                                                                    106        2010/04   Vacant Building Supplement
30              2010/12   Certificate of Garage Insurance
                                                                                                    125        2011/09   Commercial Insurance Application - Applicant Information Section
31              2012/08   Certificate of Marine / Energy Insurance
                                                                                                    126        2011/09   Commercial General Liability Section
35              2011/09   Cancellation Request / Policy Release
                                                                                                    127        2012/03   Business Auto Section
36              2007/01   Agent/Broker of Record Change
                                                                                                    128        2012/04   Garage and Dealers Section
37              2008/01   Statement of No Loss
                                                                                                    129        2009/11   Vehicle Schedule
42              2009/07   Residential Property Replacement Cost
                                                                                                    130        2012/07   Workers Compensation Application
45              2009/04   Additional Interest Schedule
                                                                                                    131        2011/11   Umbrella Section
50              2007/02   Automobile Insurance ID Card
                                                                                                    132        2012/04   Truckers / Motor Carriers Section
50 WM           2007/03   Automobile Insurance ID Card (with Watermark)
                                                                                                    133        2012/04   Workers Compensation Insurance Plan - Assigned Risk Section
54              1/97      Financial Responsibility Form
                                                                                                    139        2004/03   Statement/Schedule of Values
57              1/97      Financial Responsibility Form - Cancellation
                                                                                                    140        2011/10   Property Section
58              2007/11   Notice of Cancellation or Termination of Policy
                                                                                                    141        2011/10   Crime Section 2000
60              2010/04   Flood Insurance Selection / Rejection
                                                                                                    143        2004/01   Transportation Section
60 US           2008/02   Insurance Supplement - Notice - Offer of Terrorism Coverage
                                                                                                    144        2011/10   Glass And Sign Supplement
                          Insurance Supplement - Standard Fire Policy Only
62 US           2008/02
                          Notice - Offer of Terrorism Coverage                                      145        2004/03   Accounts Receivable/Valuable Papers

63              2010/07   Fraud Statements                                                          146        2007/02   Equipment Floater Section
                          Insurance Supplement - Workers' Compensation Only                         147        2001/02   Installation/Builder's Risk Section
64 US           2008/02
                          Notice - Offer of Terrorism Coverage
                                                                                                    148        2000/02   Electronic Data Processing Section
                          Personal Insurance Supplement - Extraordinary Life
66              2011/05
                          Circumstances                                                             149        2007/10   Dealers Section

70              2012/03   Personal Policy Change Request (Except Auto)                              155 BM     2004/12   Boiler & Machinery Section 2002

71              2012/03   Personal Auto Policy Change Request                                       159        2004/03   Schedule of Insurance

72              2009/10   Mobile Home Supplement                                                    160        2011/10   Business Owners Application


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                        ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                           Page 1 of 12
                                                                                ACORD Forms Index
                                                   All packages contain 100 forms - Please specify number of packages required
                                                                           COUNTRYWIDE P&C FORMS - continued
 Number   Edition   Title                                                             Quantity    Number   Edition   Title                                                            Quantity
163       2012/06   Commercial Auto Driver Information Schedule                                  404       2007/09   Agriculture Liability Section

175       2012/04   Commercial Policy Change Request                                             405       2007/09   Agriculture Premises Diagram

180       1/97      Errors and Omissions Section - Electronic Data Processors, etc.                                  Agriculture Supplement - Unscheduled Farm Personal Property
                                                                                                 406       2007/09
                                                                                                                     Inventory Form
185       2011/09   Restaurant/Tavern Supplement
                                                                                                 407       2011/11   Livestock Mortality Section
186       2011/10   Contractors Supplement
                                                                                                 408       2007/09   Equine Liability Supplement
187       3/98      Professional Liability Supplement
                                                                                                 410       2011/11   Small Farm/Ranch Application
188       2010/06   Employment Related Practices Liability Section
                                                                                                 501       2004/07   Surety Report of Execution
190       2011/11   Supplemental Property Application
                                                                                                 610       2009/04   Premium Payment Supplement
193       2001/02   Open Cargo Section
                                                                                                 801       2002/01   Railroad Protective Liability Supplement
194       2009/03   Truckers / Motor Carrier Supplement
                                                                                                 802       2011/09   Hotel / Motel Supplement
195       10/96     Design Professional's Individual Property Survey
                                                                                                 803       2011/10   Liquor Liability Section
196       2011/10   Medical Professional Liability Insurance Application
                                                                                                 807       2009/12   Directors & Officers Liability Section
199       1/99      Application Supplement - Undertaking
                                                                                                 808       2010/08   P&C Agency Appointment Form
200       3/93      Producer Account
                                                                                                                     Business Income / Extra Expense / Rental Value
                                                                                                 810       2011/10
201       3/93      Producer Account Discrepancy Notice                                                              Supplement to Property Section
210       2001/05   Yacht Section                                                                811       2011/10   Value Reporting Information Supplement to Property Section

225       1/98      Policyholder's Report                                                        812       2006/02   Agency Questionnaire

226       3/93      Statement of Premium Adjustment                                              813       2005/03   Request for Proof of Property Insurance

275       2009/05   Aviation Insurance Binder                                                    815       2009/02   International Liability Exposure Supplement

276       2009/05   Aircraft Insurance Binder                                                    816       2005/06   International Property Exposure Supplement

281       2011/10   Personal Inland Marine Section                                               817       2010/08   P&C Producer Appointment Form - Appointment Section

282       2012/03   Watercraft Section                                                           818       2007/08   P&C Producer Appointment Form - Background Questions

283       2012/02   Personal Umbrella Application Section                                                            P&C Producer Appointment Form - Additional Appointment or
                                                                                                 819       2010/08
                                                                                                                     Termination
301       2010/10   National Flood Insurance Program - Flood Insurance Application
                                                                                                 822       2009/07   Driver Work / School Address Information Supplement
302       2010/10   NFIP - Flood Insurance General Change Endorsement
                                                                                                 823       2011/10   Additional Premises Information Schedule
303       2010/10   NFIP - Flood Insurance Preferred Risk Policy Application
                                                                                                                     Professional / Specialty Insurance Application - For Use in
                                                                                                 825       2011/09
304       2010/10   NFIP - Flood Insurance Cancellation / Nullification                                              Management, Executive & Professional Lines - Applicant Section
305       2012/02   NFIP - Credit Card Payment Form                                              827       2008/01   Employment Practices Liability Insurance Section
                    NFIP - Rating Information and Elevated Building Determination                828       2011/09   Fiduciary Liability Coverage Section
306       2011/04
                    Form
                                                                                                 829       2009/05   Forms and Endorsements Schedule
307       2011/04   NFIP - Floodproofing Certificate for Non-Residential Structures
                                                                                                 830       2008/11   Property Insurance Card
308       2011/04   NFIP - Residential Basement Floodproofing Certificate
                                                                                                 831       2010/12   Professional / Specialty Insurance Notice of Incident / Claim
325       2011/11   Aviation Insurance Application - Applicant Information Section
                                                                                                 832       2011/09   Miscellaneous E&O Section
326       2006/04   Airport Property Supplement
                                                                                                 833       2011/07   Lawyers Professional Liability Section
327       2006/04   Airport and FBO Liability Section
                                                                                                 834       2011/09   Cyber and Privacy Coverage Section
328       2006/04   Private Hangar Liability Section

329       2009/06   Aviation Products Liability

330       2009/04   Aircraft Section

331       2011/11   Pilot Experience

332       2006/04   Hangar Schedule

333       2009/05   Aircraft Schedule

335       2009/06   Aviation Policy Change Request – Applicant Information Section

336       2009/06   Airport Property Change Request

337       2009/06   Airport and FBO Liability Change Request

338       2009/06   Private Hangar Liability Change Request

339       2009/06   Aviation Products Liability Change Request

340       2009/06   Aircraft Change Request

341       2011/11   Pilot Experience Change Request

342       2009/06   Hangar Change Request

350 WM              Watermark Paper - 20 # ID Card Stock (4-part perforation)

360 WM              Watermark Paper - 32 # ID Card Stock (4-part perforation)

370 WM              Watermark Paper - 32 # ID Card Stock (non-perforated)

401       2011/11   Agriculture Application

402       2009/03   Agriculture Property Section

403       2007/09   Agriculture Prop Sect - Scheduled/Unscheduled Personal Property


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                   ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                      Page 2 of 12
                                                                                ACORD Forms Index
                                                 All packages contain 100 forms - Please specify number of packages required
                                                                                         STATE P&C FORMS
 Number   Edition   Title                                                                 Quantity    Number    Edition   Title                                                                Quantity
                                          Alabama                                                                                    California (continued)
50 AL     2007/10   Alabama Insurance Identification Card                                            860 CA     2004/12   California Auto Supplement - Driver Self Certification

62 AL     5/98      Alabama Insurance Application Supplement                                         861 CA     2011/07   California Residential Property Insurance Bill of Rights

90 AL     2010/11   Alabama Personal Auto Application                                                                                          Colorado
137 AL    2010/11   Alabama Commercial Auto                                                          50 CO      2007/03   Colorado Insurance Identification Card

138 AL    2012/04   Alabama Garage and Dealers                                                       61 CO      2012/01   Colorado Auto Supplement - Summary of Coverages

290 AL    2010/11   Alabama Personal Automobile Application Section                                  62 CO      2/97      Colorado Personal Property Supplement - Coverage Disclosure

                                          Alaska                                                     64 CO      2009/01
                                                                                                                          Colorado Auto Supplement - Colorado Offer of Medical Payments
                                                                                                                          Coverage
61 AK     7/97      Alaska Auto Supplement - UM/UIM Coverage Selection
                                                                                                     90 CO      2010/08   Colorado Personal Automobile Application
62 AK     2/98      Alaska Auto Supplement - Exclusion of Named Drivers
                                                                                                     137 CO     2011/06   Colorado Commercial Auto
90 AK     2011/12   Alaska Personal Auto Application
                                                                                                     138 CO     2012/02   Colorado Garage and Dealers
137 AK    2011/12   Alaska Commercial Auto
                                                                                                     171 CO     2006/01   Colorado Rejection of Coverage by Corporate Officers
138 AK    2012/04   Alaska Garage and Dealers
                                                                                                     290 CO     2010/08   Colorado Personal Automobile Application Section
171 AK    6/98      Alaska Petition For Executive Officer Waiver
                                                                                                                                            Connecticut
290 AK    2011/12   Alaska Personal Auto Application Section
                                                                                                                          Notice of Information Practices (Privacy) for states
                                                                                                     38         2012/07
                                        Arkansas                                                                          of CA / CT / GA / IL / NV / NJ / RI / WA
50 AR     2007/10   Arkansas Proof of Insurance Card                                                 50 CT      2009/01   Connecticut Insurance Identification Card

61 AR     2010/04   Arkansas Auto Supplement UM/UIM Coverage                                         61 CT      2010/01   Connecticut Auto Supplement - UM Coverage
                    Arkansas Property Supplement - Declination of                                                         Connecticut Personal Insurance Supplement - Summary of
67 AR     2000/02                                                                                    62 CT      2011/07
                    Residential Earthquake Coverage                                                                       Consumer Protections
90 AR     2010/06   Arkansas Personal Auto Application                                               66 CT      2006/06   Connecticut FAIR Plan Application for Property/Liability Insurance

137 AR    2010/08   Arkansas Commercial Auto                                                         90 CT      2011/01   Connecticut Personal Auto Application

138 AR    2012/06   Arkansas Garage and Dealers                                                      137 CT     2011/01   Connecticut Commercial Auto

290 AR    2010/06   Arkansas Personal Auto Application Section                                       138 CT     2012/04   Connecticut Garage and Dealers

                                          Arizona                                                    171 CT     2006/08   Connecticut Workers' Comp. Comm. - Coverage Election by
                                                                                                                          Employee Who Is an Officer of a Corporation, Manager of an
38 AZ     2003/10   Arizona Notice of Information Practices (Privacy)                                                     LLC, or Member of a Multiple-Member LLC
50 AZ     2012/08   Arizona Insurance Identification Card                                            172 CT     2006/08   Connecticut Workers' Comp. Comm. - Coverage Election by
                                                                                                                          Employees who are Members of a Partnership
61 AZ     2001/02   Arizona Auto Supplement UM/UIM Coverage Selection
                                                                                                                          Connecticut Workers' Comp. Comm. - Coverage Election by Sole
                                                                                                     173 CT     2006/08
90 AZ     2012/04   Arizona Personal Auto Application                                                                     Proprietor or Single-Member LLC
137 AZ    2010/11   Arizona Commercial Auto                                                          290 CT     2011/01   Connecticut Personal Automobile Application Section

138 AZ    2012/04   Arizona Garage and Dealers                                                                                                 Delaware
290 AZ    2010/11   Arizona Personal Automobile Application Section                                                       Delaware Personal Insurance Supplement
                                                                                                     38 DE      2008/04
                                                                                                                          Notice of Information Practices (Privacy)
                                        California
                                                                                                     50 WM      2007/03   Automobile Insurance ID Card (with Watermark)
                    Notice of Information Practices (Privacy) for states
38        2012/07                                                                                                         DE Auto Supplement, DE Motorist's Protection Act - Required
                    of CA / CT / GA / IL / NV / NJ / RI / WA                                         61 DE      2006/10
                                                                                                                          Statement to Policyholders
50 CA     2004/07   California Insurance Identification Card
                                                                                                     62 DE      2004/10   DE Auto Supplement, PIP Deductible Options
51 CA     2004/07   California Evidence of Liability Insurance
                                                                                                                          Insurance Placement Facility of Delaware
                                                                                                     64 DE      2010/05
52 CA     2007/07   California Fleet Auto Insurance Identification Card                                                   Basic Property Insurance Application
                    California Auto Supplement - Mandatory UM Bodily Injury /                        65
61 CA     2008/03                                                                                               2006/08   FAIR Plan Supplementary Questionnaire
                    Property Damage Coverage Offer                                                   PA/DE/WV
64 CA     2004/02   California Insurance Supplement - Agency Language                                67 DE      2012/01   Delaware Insurance Supplement

65 CA     2004/07   California Insurance Supplement - Race, National Origin, Gender                  90 DE      2010/06   Delaware Personal Auto Application

66 CA     2011/04   California Offer of Earthquake Coverage                                          137 DE     2010/08   Delaware Commercial Auto

67 CA     2011/07   California Residential Property Insurance Disclosure                             138 DE     2012/06   Delaware Garage and Dealers
                    California Scheduled Personal Property Loss Computation                          171 DE     2006/01   Delaware Executive Officer(s) Exclusion
68 CA     2001/03
                    Disclosure
                                                                                                     290 DE     2010/06   Delaware Personal Auto Application Section
90 CA     2010/12   California Personal Auto Application

137 CA    2010/12   California Commercial Auto

138 CA    2012/04   California Garage and Dealers

177 CA    2001/03   California Auto Body Repair Consumer Bill of Rights
290 CA    2010/12   California Personal Auto Application Section
                    California FAIR Plan Property Insurance - Application for Dwelling
854 CA    2012/06
                    Insurance
                    California FAIR Plan Property Insurance - Application for
855 CA    2011/02
                    Commercial Insurance
                    California FAIR Plan Property Insurance - Application for
856 CA    2011/02
                    Businessowners (BOP) Insurance
                    California Earthquake Authority - Application for Earthquake
857 CA    2011/02
                    Insurance

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                       ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                          Page 3 of 12
                                                                                  ACORD Forms Index
                                                  All packages contain 100 forms - Please specify number of packages required
                                                                                STATE P&C FORMS - continued
 Number   Edition   Title                                                                 Quantity    Number   Edition   Title                                                              Quantity
                                 District of Columbia                                                                                           Hawaii
                    Application to District of Columbia Property Insurance Facility for              50 HI     2008/01   Hawaii Auto ID Card
64 DC     2010/11
                    Basic Property Insurance
                                                                                                     60 HI     2010/07   Hawaii Auto Supplement - UM/UIM/PIP
                    District of Columbia Property Insurance Facility - Essential
66 DC     2010/10
                    Homeowners Insurance Inspection and Placement Application p. 1                   90 HI     2011/12   Hawaii Personal Auto Application
                    District of Columbia Property Insurance Facility - Essential                     94 HI     2001/03   Hawaii Vehicle Inspection Report Supplement
67 DC     2010/10
                    Homeowners Insurance Inspection and Placement Application p. 2
                                                                                                     137 HI    2011/12   Hawaii Commercial Auto
90 DC     2011/01   District of Columbia Personal Auto Application
                                                                                                     138 HI    2012/05   Hawaii Garage and Dealers
137 DC    2011/01   District of Columbia Commercial Auto
                                                                                                     290 HI    2011/12   Hawaii Personal Auto Application Section
138 DC    2012/04   District of Columbia Garage and Dealers
                                                                                                                                                 Idaho
290 DC    2011/01   District of Columbia Personal Auto Application Section
                                                                                                     50 ID     2007/10   State of Idaho Liability Insurance Identification Card
                                          Florida
                                                                                                                         Idaho Auto Supplement - Idaho Uninsured Motorist and
                                                                                                     61 ID     2009/01
50 FL     2009/07   Florida Personal Auto ID Card                                                                        Underinsured Motorist Disclosure Statement
51 FL     2009/07   Florida Commercial Auto ID Card                                                  90 ID     2010/08   Idaho Personal Auto Application

61 FL     2011/10   Florida Auto Supplement - Rejection/Election of UM Coverage                      137 ID    2011/07   Idaho Commercial Auto

62 FL     2011/10   Florida Auto Supplement - Personal Injury Protection Options                     138 ID    2012/02   Idaho Garage and Dealers
                    Florida Auto Supplement - Notice to Policyholders - Florida                      290 ID    2010/08   Idaho Personal Automobile Application Section
64 FL     2011/10
                    Notification of Availability of Uninsured Motorist Coverage
                                                                                                                                                Illinois
65 FL     2007/08   Florida Residential Property Supplement
                                                                                                                         Notice of Information Practices (Privacy) for states
                    Florida Insurance Supplement                                                     38        2012/07
66 FL     2001/08                                                                                                        of CA / CT / GA / IL / NV / NJ / RI / WA
                    Credit Report Disclosure Information
                                                                                                     50 IL     2007/03   Illinois Insurance Identification Card
67 FL     7/94      Florida Homeowners Supplement
                                                                                                     61 IL     2003/03   Illinois Auto Supplement - UM/UIM
                    Citizens Property Insurance Corporation
68 FL     2004/09                                                                                                        Illinois Property Supplement - Notice of Availability of
                    Residential - Dwelling Wind Only                                                 62 IL     2007/08
                                                                                                                         Earthquake Insurance
                    Citizens Property Insurance Corporation
69 FL     2004/09                                                                                                        Mine Subsidence Property Insurance Supplement
                    Wind Only Supplemental Residential - Application Schedule                        67        2011/07
                                                                                                                         Illinois, Indiana, Kentucky, West Virginia
                    Florida Property Supplement
70 FL     2012/02
                    Uniform Mitigation Verification Inspection Form                                  67 IL     2012/01   Illinois Insurance Supplement - Civil Union Disclosure
90 FL     2008/05   Florida Personal Auto Application                                                90 IL     2012/03   Illinois Personal Auto Application
                    Florida Commercial Insurance Application                                         137 IL    2011/03   Illinois Commercial Auto
125 FL    2011/10
                    Applicant Information Section
                                                                                                     138 IL    2012/03   Illinois Garage and Dealers
130 FL    2002/07   Florida Workers Compensation Application
                                                                                                     171 IL    2005/06   Illinois FAIR Plan Application for Commercial Property Insurance
133 FL    2011/01   Florida Workers Comp. Addendum to ACORD 130 FL
                                                                                                     290 IL    2012/03   Illinois Personal Auto Application Section
                    Florida Workers Comp. Instructions for
134 FL    2010/01
                    Completing ACORD 130 FL and 133 FL                                                                                          Indiana
137 FL    2011/10   Florida Commercial Auto                                                          50 IN     2007/11   Indiana Insurance Identification Card
138 FL    2011/10   Florida Garage and Dealers                                                                           Mine Subsidence Property Insurance Supplement
                                                                                                     67        2011/07
                                                                                                                         Illinois, Indiana, Kentucky, West Virginia
171 FL    2004/04   Florida Notice of Election of Coverage
                                                                                                     90 IN     2010/08   Indiana Personal Auto Application
172 FL    2007/08   Florida Revocation of Election to be Exempt
                                                                                                     137 IN    2011/07   Indiana Commercial Auto
174 FL    2007/08   Florida Revocation of Election of Coverage
                                                                                                     138 IN    2012/02   Indiana Garage and Dealers
175 FL    3/97      Florida Workers Compensation Monthly Change Sheet
                                                                                                     290 IN    2010/08   Indiana Personal Auto Application Section
                    Citizens Property Insurance Corporation
220 FL    2003/08
                    Commercial and Commercial - Residential Wind Only                                                                             Iowa
                    Citizens Property Ins Corp, Wind Only - Supplemental Application                 50 IA     2007/08   Iowa Financial Responsibility Card
221 FL    2002/07
                    Schedule Commercial and Commercial - Residential
                                                                                                     61 IA     2002/02   Iowa Auto Supplement - UM/UIM Offer/Rejection
860 FL    2011/11   Florida Commercial Auto Addendum
                                                                                                     62 IA     2/98      Iowa Auto Supplement - Notice Regarding UM/UIM Coverage
                                          Georgia
                                                                                                     64 IA     2/98      Iowa Auto Supplement - UM/UIM Stacking Coverage Notice
                    Notice of Information Practices (Privacy) for states
38        2012/07
                    of CA / CT / GA / IL / NV / NJ / RI / WA                                         65 IA     2008/01   Iowa Auto Supplement - Aftermarket Crash Parts

50 GA     2008/11   Georgia Insurance Policy Information Card                                                            Iowa Personal Insurance Supplement
                                                                                                     66 IA     2006/07
                                                                                                                         Disclosure Use of Claims History
51 GA     2005/01   Georgia Fleet Policy Information Card
                                                                                                                         Iowa Personal Insurance Supplement
                    Georgia Auto Supplement - Georgia Auto Disclosure Form,                          67 IA     2010/07
64 GA     2009/01                                                                                                        Extraordinary Life Circumstances Disclosure
                    Notice to Policyholders, Uninsured Motorist Coverage Selection
                                                                                                     90 IA     2011/01   Iowa Personal Auto Application
90 GA     2010/08   Georgia Personal Auto Application
                                                                                                     137 IA    2011/02   Iowa Commercial Auto
137 GA    2011/07   Georgia Commercial Auto
                                                                                                     138 IA    2012/05   Iowa Garage and Dealers
138 GA    2012/02   Georgia Garage and Dealers
                                                                                                     290 IA    2011/01   Iowa Personal Automobile Application Section
171 GA    2001/03   Georgia Workers' Comp - Corporate Officer Rejection
290 GA    2010/08   Georgia Personal Automobile Application Section




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                       ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                          Page 4 of 12
                                                                                ACORD Forms Index
                                                 All packages contain 100 forms - Please specify number of packages required
                                                                               STATE P&C FORMS - continued
 Number   Edition   Title                                                                  Quantity    Number   Edition   Title                                                              Quantity
                                          Kansas                                                                                              Maryland
                    Kansas Personal Insurance Supplement - Notice of Insurance                        39 MD     2003/05   Maryland Application Supp Notice of Intent to Use Credit History
38 KS     2011/05
                    Information Practices
                                                                                                      62 MD     1/98      Maryland Commercial Auto Supplement
90 KS     2012/02   Kansas Personal Auto Application
                                                                                                                          Maryland Property Insurance Availability Program
                                                                                                      64 MD     2010/11
137 KS    2011/03   Kansas Commercial Auto                                                                                Essential Property Insurance Inspection and Placement
138 KS    2012/03   Kansas Garage and Dealers                                                                             Maryland Property Insurance Availability Program - Essential
                                                                                                      65 MD     2010/10   Homeowners Insurance Inspection and Placement (p. 1 of 2)
171 KS    2005/11   Kansas Elec. of Individual, Partner or Self-Employed Individual
                                                                                                                          Maryland Property Insurance Availability Program - Essential
                    Kansas Cancel. of Elec. of Individual, Partner or Self-Employed Ind.              66 MD     2010/10
172 KS    2005/11                                                                                                         Homeowners Insurance Inspection and Placement (p. 2 of 2)
173 KS    2005/11   Kansas Cancellation of Election Not to Accept Coverage                                                Maryland Personal Auto Supplement - Mandatory Offer of
                                                                                                      67 MD     2011/01   Increased Liability Coverage for Claims of Family Members,
174 KS    2005/11   Kansas Election Not to Accept Coverage                                                                Mandatory PIP Waiver, and Mandatory UM Coverage Waiver
176 KS    2005/11   Kansas Election of Employer to Cover Employees                                                        Maryland Personal Property Supplement - Statement Regarding
                                                                                                      68 MD     2007/01
                                                                                                                          Flood Insurance
177 KS    2005/11   Kansas Election of Coverage for Volunteer Workers
                                                                                                      69 MD     2007/01   Maryland Insurance Supplement - Notice of Underwriting Period
178 KS    2005/11   Kansas Cancellation of Election of Employer to Cover Employees
                                                                                                      90 MD     2012/05   Maryland Personal Auto Application
179 KS    2005/11   Kansas Cancel. of Election of Coverage for Volunteer Workers
                                                                                                      137 MD    2012/05   Maryland Commercial Auto
180 KS    2005/11   Kansas Election of Coverage for Persons Performing Public Service
                                                                                                      138 MD    2012/05   Maryland Garage and Dealers
                    Kansas Cancellation of Election of Coverage for Persons
181 KS    2005/11
                    Performing Public Service                                                         290 MD    2012/05   Maryland Personal Automobile Application Section

182 KS    2001/05   Kansas Election of a Noncompensated Volunteer to be Covered                                           Maryland Personal Property Supplement - Loss from Water and
                                                                                                      851 MD    2008/11
                                                                                                                          Sewer Backup
                    Kansas Cancellation of Election of a Noncompensated Volunteer
183 KS    2001/05                                                                                                         Maryland Personal Property Supplement - Homeowner's
                    to be Covered                                                                     852 MD    2012/10
                                                                                                                          Insurance, Limitation of Claims Made Notice
290 KS    2012/02   Kansas Personal Auto Application Section
                                                                                                                                          Massachusetts
                                        Kentucky
                                                                                                                          Massachusetts Property Insurance Underwriting Association
                                                                                                      60 MA     2012/07
50 KY     2006/01   Commonwealth of Kentucky Proof of Insurance                                                           Application for Homeowners Insurance
64 KY     2011/01   Kentucky FAIR Plan Homeowners Application                                                             Massachusetts Property Insurance Underwriting Association
                                                                                                      61 MA     2003/04
                                                                                                                          Instructions to Complete Homeowners Application ACORD 60 MA
65 KY     2011/01   Kentucky FAIR Plan Dwelling Fire Application
                                                                                                                          Massachusetts Residential Property Liability Supplement
                                                                                                      64 MA     2/97
66 KY     2011/01   Kentucky FAIR Plan Farm Fire Application                                                              Lead Poisoning Liability Disclosure Notice
                    Mine Subsidence Property Insurance Supplement                                                         Massachusetts Property Insurance Underwriting Association -
67        2011/07                                                                                     65 MA     2012/07
                    Illinois, Indiana, Kentucky, West Virginia                                                            Application for Dwelling Fire Insurance Inspection and Placement
68 KY     2011/01   Kentucky FAIR Plan Commercial Fire Application                                                        Massachusetts Property Ins Underwriting Assn - Instructions for
                                                                                                      66 MA     2005/01
                                                                                                                          Completing Dwelling Fire Application ACORD 65 MA
90 KY     2011/03   Kentucky Personal Auto Application
                                                                                                                          Massachusetts Property Ins Underwriting Assn - Application for
                                                                                                      67 MA     2003/04
137 KY    2011/03   Kentucky Commercial Auto                                                                              Commercial Fire Insurance Inspection and Placement
138 KY    2012/05   Kentucky Garage and Dealers                                                                           Massachusetts Property Insurance Underwriting Association
                                                                                                      68 MA     2003/04   Inspection Notice, Credit Reporting Notice and Instructions for
290 KY    2011/03   Kentucky Personal Auto Application Section                                                            Completing Commercial Fire Application ACORD 67 MA
                                        Louisiana                                                     69 MA     2010/07   Massachusetts Residential Property Liquid Fuel Spill Supplement

50 LA     2008/03   Louisiana Auto ID Card                                                            90 MA     2012/08   Application for Massachusetts Motor Vehicle Insurance

60 LA     4/98      Louisiana Dwelling Supplement - Loss Settlement DWG1                              95 MA     2009/12   Massachusetts Renewal Application (Statement of Facts)
61 LA     2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO4)                           137 MA    2012/02   Massachusetts Commercial Auto
62 LA     4/98      Louisiana Commercial Property Supplement                                          138 MA    2012/02   Massachusetts Garage and Dealers

64 LA     2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO2 & 3)

65 LA     2001/02   Louisiana Homeowners Supplement - Loss Settlement (HO6)

66 LA     4/98      Louisiana Dwelling Supplement - Loss Settlement DWG2 & 3

67 LA     5/98      Louisiana Certification of Mobile Home Tie Downs

68 LA     4/98      Louisiana Plan Services Application for Insurance

90 LA     2010/06   Louisiana Personal Auto Application

137 LA    2010/06   Louisiana Commercial Auto

138 LA    2012/06   Louisiana Garage and Dealers

290 LA    2010/06   Louisiana Personal Auto Application Section

861 LA    2005/07   Louisiana Auto Supplement - Active Military Personnel Affidavit

862 LA    2009/06   Louisiana Property Supplement - Hurricane Loss Mitigation Survey

                                           Maine
50 ME     2007/08   Maine Motor Vehicle Insurance Identification Card

90 ME     2011/02   Maine Personal Auto Application

137 ME    2011/02   Maine Commercial Auto

138 ME    2012/04   Maine Garage and Dealers

290 ME    2011/02   Maine Personal Auto Application Section




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                      ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                         Page 5 of 12
                                                                               ACORD Forms Index
                                                  All packages contain 100 forms - Please specify number of packages required
                                                                               STATE P&C FORMS - continued
 Number   Edition   Title                                                               Quantity    Number   Edition   Title                                                            Quantity
                                        Michigan                                                                                             Nevada
50 MI     2010/08   State of Michigan Certificate of No-Fault Insurance                                                Notice of Information Practices (Privacy) for states
                                                                                                   38        2012/07
                                                                                                                       of CA / CT / GA / IL / NV / NJ / RI / WA
                    Michigan Automobile Insurance Placement Facility
60 MI     2010/03
                    Michigan Auto Supplement - Declaration of Intent to Reside                     51 NV     2010/05   Nevada Temporary Insurance Identification Card

62 MI     2010/03   Michigan Collision Insurance Options Notice                                    52 NV     2010/05   Nevada Permanent Insurance Identification Card

64 MI     2000/10   Michigan Basic Property Insurance Assn Insurance Application                                       Nevada Temporary Insurance Identification Card, Evidence of
                                                                                                   53 NV     2011/05
                                                                                                                       Operator's Policy of Liability Insurance
90 MI     2012/10   Michigan Personal Auto Application
                                                                                                                       Nevada Permanent Insurance Identification Card, Evidence of
                                                                                                   54 NV     2011/05
133 MI    2012/08   Michigan Application for Workers' Compensation Insurance                                           Operator's Policy of Liability Insurance
137 MI    2012/10   Michigan Commercial Auto                                                                           Nevada Auto Supplement, Mandatory Offer of Medical Payments
                                                                                                   61 NV     2002/12
                                                                                                                       Coverage and Uninsured Motorists Coverage
138 MI    2012/10   Michigan Garage and Dealers
                                                                                                   62 NV     2001/05   Nevada Umbrella Supplement
                    Michigan Automobile Insurance Placement Facility Supplement to
139 MI    2004/07   ACORD App. - Application for Commercial, Public Automobiles                    90 NV     2011/04   Nevada Personal Auto Application
                    and Corporately Owned Vehicles
                                                                                                   137 NV    2011/04   Nevada Commercial Auto
171 MI    2005/01   Michigan Notice of Election
                                                                                                   138 NV    2012/05   Nevada Garage and Dealers
172 MI    4/96      Michigan App for Exclusion of Partner(s), Spouse, Child or Parent
                                                                                                   290 NV    2011/04   Nevada Personal Auto Application Section
173 MI    2000/09   Michigan WC Placement Facility Specific Person Exclusion
                                                                                                                                       New Hampshire
290 MI    2012/10   Michigan Personal Automobile Application Section
                                                                                                   90 NH     2010/06   New Hampshire Personal Auto Application
860 MI    2010/03   Michigan Auto Supplement - Declaration of Intent to Reside
                                                                                                   137 NH    2010/06   New Hampshire Commercial Auto
                                       Minnesota
                                                                                                   138 NH    2012/04   New Hampshire Garage and Dealers
38 MN     2011/05   Minnesota Authorization
                                                                                                   290 NH    2010/06   New Hampshire Personal Auto Application Section
62 MN     2000/01   Minnesota Auto Supplement
                                                                                                                                        New Jersey
65 MN     2012/04   Minnesota Insurance Guarantee Association Notice
                                                                                                                       Notice of Information Practices (Privacy) for states
                                                                                                   38        2012/07
90 MN     2011/06   Minnesota Personal Auto Application                                                                of CA / CT / GA / IL / NV / NJ / RI / WA
137 MN    2011/06   Minnesota Commercial Auto                                                      50 NJ     2005/05   Temporary State of New Jersey Insurance Identification Card

138 MN    2012/05   Minnesota Garage and Dealers                                                   50 WM     2007/03   Automobile Insurance ID Card (with Watermark)

290 MN    2011/06   Minnesota Personal Auto Application Section                                    51 NJ     2007/06   Permanent State of New Jersey Insurance Identification Card

853 MN    2010/08   Minnesota Homeowners Personal Property Supplement                              60 NJ     2001/10   New Jersey Homeowners Insurance Supplement Flood Exclusion

                                       Mississippi                                                 61 NJ     2011/07   New Jersey Auto Insurance Buyer's Guide

50 MS     2008/01   Mississippi Auto Insurance ID Card                                             62 NJ     2006/10   New Jersey Auto Supplement - Basic Policy Coverage

61 MS     2006/01   Mississippi Auto Supplement - Non-Stacking UM Insurance                        64 NJ     2010/03   New Jersey Auto Supplement - Standard Policy Coverage

90 MS     2011/02   Mississippi Personal Auto Application                                          65 NJ     2003/02   New Jersey Property Insurance Supplement - Earthquake

137 MS    2011/02   Mississippi Commercial Auto                                                                        New Jersey Auto Insurance Buyer's Guide
                                                                                                   66 NJ     2011/07
                                                                                                                       Commercial PPA Edition
138 MS    2012/04   Mississippi Garage and Dealers
                                                                                                   67 NJ     2010/08   NJUIA Dwelling Fire Application
139 MS    2/99      Mississippi Statement/Schedule of Values
                                                                                                   68 NJ     2010/05   NJUIA Commercial Fire Application
290 MS    2011/02   Mississippi Personal Auto Application Section
                                                                                                   90 NJ     2011/06   New Jersey Personal Auto Application
                                         Missouri
                                                                                                   94 NJ     2006/04   Insurance Inspection Report
50 MO     2007/05   Missouri Auto Insurance ID Card
                                                                                                                       New Jersey Workers Compensation Insurance Plan
                    Missouri Property Supplement - Notice of Availability of                       132 NJ    2006/07
62 MO     2007/08                                                                                                      Instructions/Rules
                    Earthquake Insurance
                                                                                                   133 NJ    2008/09   New Jersey Workers Compensation Insurance Application
67 MO     2009/06   Missouri FAIR Plan Insurance Application
                                                                                                                       New Jersey Workers Compensation Insurance Plan
                                                                                                   134 NJ    2007/01
90 MO     2010/10   Missouri Personal Auto Application                                                                 Notice of Election - Proprietors and Partners
137 MO    2012/01   Missouri Commercial Auto                                                                           New Jersey Workers Compensation Insurance Plan
                                                                                                   135 NJ    2009/09
                                                                                                                       Supplemental Employee Leasing Application
138 MO    2012/01   Missouri Garage and Dealers
                                                                                                                       New Jersey Workers Compensation Insurance Plan
                                                                                                   136 NJ    2009/09
290 MO    2010/10   Missouri Personal Auto Application Section                                                         Truckers Supplemental Application

                                         Montana                                                   137 NJ    2011/06   New Jersey Commercial Auto
60 MT     2003/09   Montana Application Supplement - Refusal to Renew                              138 NJ    2012/04   New Jersey Garage and Dealers

90 MT     2010/06   Montana Personal Auto Application                                                                  New Jersey Workers Compensation Insurance Plan - NJ Workers
                                                                                                   171 NJ    2003/07
                                                                                                                       Compensation and Employers Liability Manual Part 3, Section 14
                    Montana State Compensation Insurance Fund
133 MT    8/98                                                                                     290 NJ    2011/06   New Jersey Personal Auto Application Section
                    Worker’s Compensation Application Supplement
137 MT    2011/12   Montana Commercial Auto

138 MT    2012/06   Montana Garage and Dealers
290 MT    2010/06   Montana Personal Auto Application Section

                                        Nebraska
50 NE     2007/01   Nebraska Auto Liability Insurance Identification Card

90 NE     2010/06   Nebraska Personal Auto Application

137 NE    2011/12   Nebraska Commercial Auto

138 NE    2012/06   Nebraska Garage and Dealers

290 NE    2010/06   Nebraska Personal Auto Application Section

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                    ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                       Page 6 of 12
                                                                               ACORD Forms Index
                                                All packages contain 100 forms - Please specify number of packages required
                                                                              STATE P&C FORMS - continued
 Number   Edition   Title                                                              Quantity    Number   Edition   Title                                                            Quantity
                                      New Mexico                                                                                       North Dakota
60 NM     2003/01   New Mexico Confidential Abuse Disclosure                                                          North Dakota Personal Insurance Supplement - Notice of
                                                                                                  38 ND     2005/08
                                                                                                                      Information Practices
                    New Mexico Auto Supplement - UM Coverage Selection/Rejection
61 NM     2010/12
                    and Rejection Of Stacked UM Coverage                                          50 ND     2007/08   North Dakota Insurance Identification Card

90 NM     2011/07   New Mexico Personal Auto Application                                          68 ND     2004/07   North Dakota Supplement to Property Insurance - Fire District

137 NM    2011/07   New Mexico Commercial Auto                                                    90 ND     2011/06   North Dakota Personal Auto Application

138 NM    2011/07   New Mexico Garage and Dealers                                                 137 ND    2011/06   North Dakota Commercial Auto

171 NM    2004/10   New Mexico Executive Employee Affirmative Election Form                       138 ND    2012/04   North Dakota Garage and Dealers

172 NM    2004/10   New Mexico Election to Accept                                                 290 ND    2011/06   North Dakota Personal Auto Application Section

173 NM    2004/10   New Mexico Revocation                                                                                                     Ohio
174 NM    2004/10   NM Limited Liability Company Member Affirmative Election Form                                     Ohio Auto Supplement - Important Optional Disclosure Notice
                                                                                                  62 OH     2011/05
                                                                                                                      Uninsured Motorist Property Damage Coverage
290 NM    2011/07   New Mexico Personal Auto Application Section
                                                                                                  67 OH     2009/07   Ohio Mine Subsidence Homeowners and Dwelling Supplement
                                        New York
                                                                                                  68 OH     2009/07   Ohio Offer of Mine Subsidence - Homeowners and Dwelling
                    New York Personal Insurance Supplement - Notice of Information
38 NY     2005/04
                    Practices                                                                     90 OH     2011/08   Ohio Personal Auto Application

39 NY     2011/03   New York Insurance Supplement                                                 137 OH    2011/08   Ohio Commercial Auto

60 NY     2008/03   New York Homeowners Supplement                                                138 OH    2012/06   Ohio Garage and Dealers

61 NY     3/94      New York Auto Supplement (Optional Basic Econ Loss)                           170 OH    2002/09   Ohio FAIR Plan - Instructions for Completion of Insurance Apps

62 NY     2009/04   New York Application For Dwelling Insurance - NYPIUA                          171 OH    2004/03   Ohio FAIR Plan - Basic Property Application

64 NY     2008/06   New York Auto Supplement - Supp UM/UIM Insurance Coverage                     172 OH    2002/09   Ohio FAIR Plan - Homeowners Supplement

65 NY     2003/01   New York Auto Supplement - Spousal Liability Coverage                         173 OH    2002/09   Ohio FAIR Plan - Dwelling Fire Supplement

66 NY     2012/01   New York Auto Supplement - Rental Reimbursement Notice                        174 OH    2002/09   Ohio FAIR Plan - Commercial Supplement

67 NY     2009/04   Instructions for Completion of ACORD 62 NY                                    175 OH    2002/09   Ohio FAIR Plan - Farm Supplement

68 NY     2002/01   New York Liability Supplement - "Claims-Made Policy"                          176 OH    2002/09   Ohio FAIR Plan - Rehabilitation Supplement
                    New York Personal Property Supplement - Important Flood                       177 OH    2002/09   Ohio FAIR Plan - Bowling Alley Supplement
69 NY     2008/08
                    Insurance Notice
                                                                                                  290 OH    2011/08   Ohio Personal Automobile Application Section
70 NY     2006/04   NYPIUA Instructions for Completing ACORD 177 NY
                                                                                                                                          Oklahoma
90 NY     2012/01   New York Personal Auto Application
                                                                                                  50 OK     2009/08   Oklahoma Owners Security Verification Form
137 NY    2012/01   New York Commercial Auto
                                                                                                  51 OK     2009/08   Oklahoma Operators Security Verification Form
138 NY    2012/06   New York Garage and Dealers
                                                                                                  60 OK     2009/11   Oklahoma Auto Supplement - UM Coverage Law
171 NY    10/96     New York Notice of Election of a Corporation
                                                                                                  61 OK     3/94      Oklahoma Auto Supplement - Election of Non-Stacked Coverage
                    New York Election of Partners or Self-Employed Persons for
172 NY    7/96                                                                                                        Oklahoma Property Supplement
                    Workers’ Compensation Coverage                                                62 OK     2006/05
                                                                                                                      Notice to Property Owners in Rural Fire Protection Districts
                    New York Election of Executive Officers of an Organization for
173 NY    7/96                                                                                    63 OK     10/97     Oklahoma Fraud Statement
                    Workers’ Compensation Coverage
                    New York Revocation of Executive Officers of an Organization for              64 OK     2007/10   Oklahoma Liability Supplement
174 NY    7/96
                    Workers’ Compensation Coverage
                                                                                                  90 OK     2011/05   Oklahoma Personal Auto Application
177 NY    2006/04   NYPIUA Application for Commercial Insurance
                                                                                                  137 OK    2011/05   Oklahoma Commercial Auto
290 NY    2012/01   New York Personal Auto Application Section
                                                                                                  138 OK    2012/06   Oklahoma Garage and Dealers
                                    North Carolina
                                                                                                  290 OK    2011/05   Oklahoma Personal Auto Application Section
62 NC     9/97      North Carolina JUA/IUA FAIR and Beach Plan Coverage Instruc.
                                                                                                                                            Oregon
64 NC     2008/04   North Carolina Property Supplement - Prop Ins Notice Disclosure
                                                                                                  38 OR     2003/05   Oregon Notice of Information Practices (Privacy)
                    North Carolina Auto Supplement - Notice of Right to Purchase
65 NC     2010/02   Higher Limits of Uninsured Motorist (UM) and Underinsured                     61 OR     2004/10   Oregon Auto Supplement - UM Coverage Selection
                    Motorist (UIM) Coverage
                                                                                                  62 OR     2006/01   Oregon Personal Lines Supplement
                    North Carolina Insurance Supplement - Consent to Obtain Credit
66 NC     8/97
                    or Consumer Investigative Report                                              90 OR     2011/04   Oregon Personal Auto Application
                    North Carolina Insurance Supplement - Policy Service Fee                      137 OR    2011/04   Oregon Commercial Auto
67 NC     2012/03
                    Schedule
                                                                                                  138 OR    2012/05   Oregon Garage and Dealers
90 NC     2010/05   North Carolina Personal Auto Application
                                                                                                  290 OR    2011/04   Oregon Personal Auto Application Section
135 NC    2012/10   North Carolina Workers Comp Insurance Plan - Application

136 NC    2012/10   NCWCIP, Instructions for Completing ACORD 135 NC App
137 NC    2010/02   North Carolina Commercial Auto

138 NC    2012/06   North Carolina Garage and Dealers

290 NC    2010/05   North Carolina Personal Automobile Application Section




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 7 of 12
                                                                                  ACORD Forms Index
                                                   All packages contain 100 forms - Please specify number of packages required
                                                                                 STATE P&C FORMS - continued
 Number    Edition   Title                                                             Quantity    Number   Edition   Title                                                            Quantity
                                       Pennsylvania                                                                                   South Carolina
50 PA      2007/09   Pennsylvania Financial Responsibility Card                                   50 SC     2007/01   South Carolina Insurance Identification Card

60 PA      2012/10   Pennsylvania UM Coverage Select/Reject                                       61 SC     2007/08   South Carolina Auto Supplement - Offer of Opt UM/UIM Coverage

61 PA      2007/08   Pennsylvania Auto Supplement - First Party Benefits Coverage                                     South Carolina Personal Property Supplement - Cancellation
                                                                                                  64 SC     2008/03
                                                                                                                      Rules Disclosure
62 PA      2012/10   Pennsylvania UIM Coverage Select/Reject
                                                                                                  90 SC     2011/09   South Carolina Personal Auto Application
                     Insurance Placement Facility of Pennsylvania
64 PA      2011/08
                     Basic Property Insurance Application                                         137 SC    2012/01   South Carolina Commercial Auto
65                                                                                                138 SC    2012/01   South Carolina Garage and Dealers
           2006/08   FAIR Plan Supplementary Questionnaire
PA/DE/WV
                                                                                                  290 SC    2011/09   South Carolina Personal Automobile Application Section
                     Insurance Placement Facility of Pennsylvania
66 PA      2011/08
                     Dwelling Property 2 - Broad Form Application Supplement                                                           South Dakota
90 PA      2011/10   Pennsylvania Personal Auto Application                                       50 SD     2007/02   South Dakota Insurance Identification Card

137 PA     2011/10   Pennsylvania Commercial Auto                                                 90 SD     2012/07   South Dakota Personal Auto Application

138 PA     2012/03   Pennsylvania Garage and Dealers                                              137 SD    2011/05   South Dakota Commercial Auto

171 PA     2002/02   Pennsylvania Application for Executive Officer Exception                     138 SD    2012/05   South Dakota Garage and Dealers

172 PA     2002/02   Pennsylvania Executive Officers Declaration                                  290 SD    2012/07   South Dakota Personal Auto Application Section

290 PA     2011/10   Pennsylvania Personal Auto Application Section                                                                      Tennessee
                                        Puerto Rico                                               50 TN     2007/02   Tennessee Insurance Identification Card

90 PR      2012/01   Puerto Rico Personal Auto Application                                        90 TN     2011/09   Tennessee Personal Auto Application

290 PR     2012/01   Puerto Rico Personal Auto Application Section                                133 TN    2012/07   Tennessee WC Ins Plan - Assigned Risk Supplement

                                       Rhode Island                                               137 TN    2011/09   Tennessee Commercial Auto
                     Notice of Information Practices (Privacy) for states                         138 TN    2012/07   Tennessee Garage and Dealers
38         2012/07
                     of CA / CT / GA / IL / NV / NJ / RI / WA
                                                                                                  290 TN    2011/09   Tennessee Personal Automobile Application Section
50 RI      2008/01   Rhode Island Insurance Identification Card
                                                                                                                                             Texas
61 RI      4/95      Rhode Island Auto Supplement, UM BI Coverage Notice
                                                                                                  50 TX     2008/11   Texas Liability Insurance Card
62 RI      2006/01   Rhode Island Prop Suppl - Notice of Flood Coverage Exclusion
                                                                                                  60 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto
                     Rhode Island Joint Reinsurance Association
64 RI      2012/07
                     Application for Homeowners Insurance Inspection and Placement                62 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto (Spanish)
                     Rhode Island Joint Reinsurance Association                                   64 TX     2003/04   Texas Windstorm Insurance Association Application
65 RI      2003/04
                     Instructions for Completing Homeowners Application ACORD 64 RI
                                                                                                  67 TX     2007/05   Texas Homeowners and Personal Property - Rights
                     Rhode Island Joint Underwriting Insurance
66 RI      2012/07   Application for Dwelling Fire and Personal Liability Insurance               68 TX     2007/05   Texas Homeowners and Personal Property - Rights (Spanish)
                     Inspection and Placement
                                                                                                  69 TX     2000/08   Texas Special Mobile Home Windstorm/Haill Application
                     Rhode Island Joint Underwriting Insurance
                     Inspection Notice, Credit Reporting Notice and Instructions for              90 TX     2011/08   Texas Personal Auto Application
67 RI      2007/03
                     Completing Dwelling Fire and Personal Liability Application
                     ACORD 66 RI                                                                  137 TX    2011/08   Texas Commercial Auto
                     Rhode Island Joint Underwriting Insurance                                    138 TX    2012/06   Texas Garage and Dealers
68 RI      2003/04   Application for Commercial Fire Insurance Inspection and
                     Placement                                                                    290 TX    2011/08   Texas Personal Automobile Application Section
                     Rhode Island Joint Underwriting Insurance                                    851 TX    2010/06   TX Personal Lines Supp. - Use of Credit Information Disclosure
69 RI      2003/04   Inspection Notice, Credit Reporting Notice and Instructions for
                     Completing Commercial Fire Application ACORD 68 RI                                               TX Personal Lines Supp. (Spanish Version) - Use of Credit
                                                                                                  852 TX    2010/06
                                                                                                                      Information Disclosure
90 RI      2010/06   Rhode Island Personal Auto Application
                                                                                                  854 TX    2012/08   Texas Risk Pool Certificate of Property Coverage
137 RI     2010/02   Rhode Island Commercial Auto
                                                                                                  855 TX    2012/08   Texas Risk Pool Certificate of Liability Coverage
138 RI     2012/03   Rhode Island Garage and Dealers

290 RI     2010/06   Rhode Island Personal Automobile Application Section




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 8 of 12
                                                                               ACORD Forms Index
                                                  All packages contain 100 forms - Please specify number of packages required
                                                                               STATE P&C FORMS - continued
 Number   Edition   Title                                                            Quantity    Number    Edition   Title                                                             Quantity
                                     United States                                                                                    West Virginia
60 US     2008/02   Insurance Supplement - Offer of Terrorism Coverage                                               West Virginia Personal Insurance Supplement
                                                                                                38 WV      2006/04
                                                                                                                     Notice of Insurance Information Practices
                    Insurance Supplement - Offer of Terrorism Coverage
62 US     2008/02
                    Standard Fire Policy Only                                                   50 WV      2008/04   West Virginia Certificate of Insurance

64 US     2008/02   Insurance Supplement - Offer of Terrorism Coverage Work Comp                60 WV      12/93     West Virginia Auto Supplement - UM/UIM Vehicle Coverage

                                            Utah                                                61 WV      2012/04   West Virginia Auto Supplement - UM Coverage Offer Split Limits

61 UT     2010/08   Utah UM/UIM Coverage Selections                                             62 WV      2012/04   West Virginia Auto Supplement - UM Coverage Offer Single Limits

63 UT     9/93      Utah Fraud Statement                                                                             West Virginia Essential Property Insurance Association
                                                                                                64 WV      2010/05
                                                                                                                     Basic Property Insurance Application
66 UT     6/94      Utah Arbitration Provisions
                                                                                                65 WV      2006/05   West Virginia Umbrella Liability Supplement Important Notice
                    Utah Auto Supplement
67 UT     10/94                                                                                 65
                    PIP Coverage, Loss of Income Waiver                                                    2006/08   FAIR Plan Supplementary Questionnaire
                                                                                                PA/DE/WV
90 UT     2011/05   Utah Personal Auto Application
                                                                                                                     West Virginia Personal and Commercial Umbrella Liability
                                                                                                66 WV      2012/04
137 UT    2011/05   Utah Commercial Auto                                                                             Supplement - UM / UIM Coverage - Offer of Split Limits
138 UT    2012/05   Utah Garage and Dealers                                                                          Mine Subsidence Property Insurance Supplement
                                                                                                67         2011/07
                                                                                                                     Illinois, Indiana, Kentucky, West Virginia
290 UT    2011/05   Utah Personal Auto Application Section
                                                                                                                     West Virginia Umbrella Liability Supplement
                                                                                                68 WV      2012/04
                                         Vermont                                                                     UM/UIM Coverage - Offer of Single Limits
50 VT     2007/02   Vermont Automobile Insurance Identification Card                            90 WV      2011/11   West Virginia Personal Auto Application

66 VT     2003/06   Vermont Insurance Supplement - Fair Credit Reporting Act                    137 WV     2011/11   West Virginia Commercial Auto

90 VT     2011/05   Vermont Personal Auto Application                                           138 WV     2012/06   West Virginia Garage and Dealers

137 VT    2011/05   Vermont Commercial Auto                                                     290 WV     2011/11   West Virginia Personal Auto Application Section

138 VT    2012/06   Vermont Garage and Dealers                                                                       West Virginia Property Supplement - Notice of Flood Coverage
                                                                                                862 WV     2005/07
                                                                                                                     Exclusion
290 VT    2011/05   Vermont Personal Auto Application Section
                                                                                                                                        Wisconsin
                                     Virgin Islands
                                                                                                4 WI       2003/04   Wisconsin Employers First Report of Injury or Disease
90 VI     2011/12   Virgin Islands Personal Auto Application
                                                                                                90 WI      2010/06   Wisconsin Personal Auto Application
290 VI    2011/12   Virgin Islands Personal Auto Application Section
                                                                                                                     Wisconsin Automobile Insurance Plan
                                                                                                97 WI      2003/10
                                          Virginia                                                                   Private Passenger Auto Application
38 VA     2011/05   Virginia Notice of Information Practices (Privacy)                          133 WI     2010/04   Wisconsin Workers Compensation Insurance Pool

60 VA     8/94      Virginia Auto Supplement - Rental Reimbursement Coverage                    134 WI     8/99      Wisconsin Supplementary Non-Election Form
                    Virginia Property Supplement                                                135 WI     8/99      Wisconsin Supplementary Election of Coverage Form
62 VA     6/97
                    Ordinance or Law Coverage; Additional Cov Available
                                                                                                136 WI     2010/04   Wisconsin Supplement Limited Other States Coverage Request
64 VA     2005/01   Virginia Property Supplement - Notice of Flood Insurance
                                                                                                137 WI     2011/12   Wisconsin Commercial Auto
67 VA     2000/11   Virginia Property Insurance Association
                                                                                                138 WI     2012/06   Wisconsin Garage and Dealers
90 VA     2010/04   Virginia Personal Auto Application
                                                                                                177 WI     2011/11   Wisconsin Automobile Insurance Plan Business Auto Application
137 VA    2010/06   Virginia Commercial Auto
                                                                                                178 WI     2011/11   Wisconsin Automobile Insurance Plan - Truckers Application
138 VA    2012/02   Virginia Garage and Dealers
                                                                                                290 WI     2010/06   Wisconsin Personal Auto Application Section
171 VA    2003/02   Virginia Rejection of Coverage - Workers' Comp Act
                                                                                                                                         Wyoming
172 VA    2003/02   Virginia Notice Terminating Prior Rejection of Coverage
                                                                                                90 WY      2012/01   Wyoming Personal Auto Application
290 VA    2010/04   Virginia Personal Auto Application Section
                                                                                                137 WY     2012/01   Wyoming Commercial Auto
                                       Washington
                                                                                                138 WY     2012/01   Wyoming Garage and Dealers
                    Notice of Information Practices (Privacy) for states
38        2012/07
                    of CA / CT / GA / IL / NV / NJ / RI / WA                                    290 WY     2012/01   Wyoming Personal Auto Application Section

90 WA     2010/10   Washington Personal Auto Application

137 WA    2011/08   Washington Commercial Auto

138 WA    2012/04   Washington Garage and Dealers

290 WA    2010/10   Washington Personal Auto Application Section




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                 ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                    Page 9 of 12
                                                 ACORD Forms Index
                             ACORD Australia Forms - Available ONLY on the ACORD Web Site
                                                                     AUSTRALIA FORMS
 Number   Edition   Title                                                    Number    Edition   Title
3020      2012/02   Home Certificate of Currency

3021      2012/02   Private Motor Certificate of Currency

3022      2012/02   Professional Indemnity Certificate of Currency

3023      2012/02   Commercial Motor Certificate of Currency

3045      2012/02   Interested Party Schedule

3080      2012/03   Home Application for Insurance

3090      2012/03   Personal Motor Application for Insurance

3098      2012/03   Personal Motor Vehicle Schedule

3101      2012/02   Additional Remarks Schedule

3129      2012/02   Commercial Motor Vehicle Schedule

3137      2012/02   Commercial Motor Application for Insurance

3163      2012/02   Commercial Driver Schedule

3823      2012/02   Additional Situations Schedule

3825      2012/02   Professional Indemnity Insurance Application

3826      2012/02   Industrial Special Risks Insurance Application

3827      2012/02   Business Package Application for Insurance




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                            ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                             Page 10 of 12
                                              ACORD Forms Index
                    ACORD Life/Annuity/Health Forms - Available ONLY on the ACORD Web Site
                                                                                 COUNTRYWIDE LIFE FORMS
 Number   Edition   Title                                                                        Number    Edition   Title
650       2011/07   Authorization for the Release of Health Information                         763        2005/03   Policy Effective Date Supplement - Date Policy Issued

651       2007/07   Electronic Funds Transfer Authorization Form for Long Term Care Insurance   764        2004/03   Fair Credit Reporting Act Disclosure

652       2007/07   Credit Card Payment Authorization Form for Long Term Care Insurance         765        2004/01   Agent's Report

653       2008/04   Policy Delivery Receipt                                                     766        2007/03   Life Product Comparison Form

701       2003/09   Life Insurance Application - Part 1                                         767        2004/03   Temporary Insurance Agreement

702       2004/03   Life Insurance Application - Part 2 Medical History                                              Life Insurance Application - Part 2 Medical History Medical
                                                                                                768        2004/03
                                                                                                                     Condition Details / Additional Care Providers
703       2004/03   Medical Examiner's Report
                                                                                                771        2005/10   Laboratory Identification Form
731       2010/05   Request for Proposal - Additional Unions Schedule
                                                                                                781        2008/01   Informal Inquiry Application - Part 2 Medical History
732       2010/05   Request for Proposal - Additional Locations Schedule
                                                                                                782        2008/01   Medical Examiner's Report
733       2010/05   Request for Proposal - Additional Covered Affiliates Schedule
                                                                                                783        2008/01   HIV Antibody/Antigen Consent and Testing Form
751       2004/11   Authorization to Obtain and Disclose Information
                                                                                                                     Informal Inquiry Application - Part 2 Medical History Medical
                                                                                                784        2008/01
752       2004/01   Illustration Certification and Acknowledgement                                                   Condition Details / Additional Care Providers
753       2004/07   Notice of Insurance Information Practices (Pre Notice)                      785        2011/07   Request for Proposal - Employee Benefits
                    Life Insurance Application Supplement - Additional Other                    786        2011/09   Request for Proposal - Life Supplement
754       2003/09
                    Proposed Insured
                                                                                                787        2011/12   Request for Proposal - Short Term Disability Supplement
755       2003/09   Life Insurance Application Supplement - Additional Owners
                                                                                                788        2010/05   Request for Proposal - Long Term Disability Supplement
756       2003/09   Life Insurance Application Supplement - Additional Beneficiaries
                                                                                                789        2010/05   Age Banded Rate Supplement
757       2004/07   HIV Antibody/Antigen Consent and Testing Form
                                                                                                790        2010/05   Reducing Benefit Duration Schedule
758       2011/03   Life, Annuity and Health Producer Appointment Form
                                                                                                791        2010/05   Administrative Services and Fee Schedule - Long Term Disability
759       2007/03   Important Notice Regarding Replacement - Model Regulation States
                                                                                                792        2010/05   Administrative Services and Fee Schedule - Short Term Disability
760       2007/03   Important Notice Regarding Replacement
                                                                                                794        2012/01   Request for Proposal - Dental and Vision Supplement
761       2005/03   Policy Effective Date Supplement - Date of Policy Application
                                                                                                951        2012/03   1035 Exchange / Rollover / Transfer Form
762       2005/03   Policy Effective Date Supplement - Date of Policy Delivery

                                                                                        STATE LIFE FORMS
 Number   Edition   Title                                                                        Number    Edition   Title
                                          Arizona                                                                                        Kentucky
751 AZ    2004/12   Arizona Authorization to Obtain and Disclose Information                    767 KY     2004/12   Kentucky Temporary Insurance Agreement

757 AZ    2004/12   Arizona HIV Antibody/Antigen Consent and Testing Form                                                                   Maine
                                       Arkansas                                                 701 ME     2003/09   Maine Life Insurance Application - Part 1

966 AR    2007/03   Arkansas Annuity Product Comparison Form                                    702 ME     2004/10   Maine Life Insurance Application - Part 2 Medical History

                                        California                                              703 ME     2004/03   Maine Medical Examiner's Report

757 CA    2004/07   California HIV Antibody/Antigen Consent and Testing Form                    751 ME     2005/02   Maine Authorization to Obtain and Disclose Information

760 CA    2007/03   California Notice Regarding Replacement                                                          Maine Life Insurance Application Supplement - Additional Other
                                                                                                754 ME     2003/09
                                                                                                                     Proposed Insured
966 CA    2007/03   California Annuity Product Comparison Form
                                                                                                757 ME     2004/07   Maine HIV Antibody/Antigen Consent and Testing Form
                                 District of Columbia
                                                                                                767 ME     2005/02   Maine Temporary Insurance Agreement
                    District of Columbia HIV Antibody/Antigen Consent and Testing
757 DC    2004/07                                                                                                    Maine Life Insurance Application - Part 2 Medical History
                    Form                                                                        768 ME     2004/10
                                                                                                                     Medical Condition Details / Additional Care Providers
                                          Florida
                                                                                                                                          Maryland
701 FL    2003/09   Florida Life Insurance Application - Part 1
                                                                                                701 MD     2005/06   Maryland Life Insurance Application - Part 1
                    Florida Life Insurance Application Supplement - Additional Other
754 FL    2003/09
                    Proposed Insured                                                            702 MD     2004/09   Maryland Life Insurance Application - Part 2 Medical History

755 FL    2003/09   Florida Life Insurance Application Supplement - Additional Owners           703 MD     2004/09   Maryland Medical Examiner's Report

756 FL    2003/09   Florida Life Insurance Application Supplement - Additional Beneficiaries    751 MD     2005/06   Maryland Authorization to Obtain and Disclose Information

757 FL    2005/03   Florida HIV Antibody/Antigen Consent and Testing Form                                            Maryland Life Insurance Application Supplement - Additional
                                                                                                754 MD     2005/06
                                                                                                                     Other Proposed Insured
759 FL    2005/06   Florida Notice to Applicant Regarding Replacement of Life Insurance
                                                                                                                     Maryland Life Insurance Application Supplement - Additional
                                                                                                755 MD     2004/09
966 FL    2007/03   Florida Annuity Product Comparison Form                                                          Owners
                    Florida Annuity Product Comparison Form Supplement - Policy / Rider                              Maryland Life Insurance Application Supplement - Additional
969 FL    2007/03                                                                               756 MD     2004/09
                    Description                                                                                      Beneficiaries

                                          Georgia                                               759 MD     2005/06   Maryland Important Notice Regarding Replacement

757 GA    2004/12   Georgia HIV Antibody/Antigen Consent and Testing Form                                            Maryland Policy Effective Date Supplement - Date of Policy
                                                                                                761 MD     2005/04
                                                                                                                     Application
                                           Hawaii
                                                                                                                     Maryland Policy Effective Date Supplement - Date of Policy
                                                                                                762 MD     2005/04
759 HI    2007/03   Hawaii Important Notice Regarding Replacement                                                    Delivery

                                              Idaho                                             763 MD     2005/04   Maryland Policy Effective Date Supplement - Date Policy Issued

760 ID    2007/03   Idaho Important Notice Regarding Replacement                                767 MD     2004/12   Maryland Temporary Insurance Agreement

                                          Indiana                                               768 MD     2005/06
                                                                                                                     Maryland Life Insurance Application - Part 2 Medical History
                                                                                                                     Medical Condition Details / Additional Care Providers
751 IN    2004/12   Indiana Authorization to Obtain and Disclose Information


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                   Page 11 of 12
                                              ACORD Forms Index
                    ACORD Life/Annuity/Health Forms - Available ONLY on the ACORD Web Site
                                                                              STATE LIFE FORMS - continued
 Number   Edition   Title                                                                          Number   Edition   Title
                                    Massachusetts                                                                                             Ohio
701 MA    2004/08   Massachusetts Simplified Issue Life Insurance Application - Part 1            757 OH    2009/02   Ohio HIV Antibody/Antigen Consent and Testing Form

702 MA    2004/08   Massachusetts Life Insurance Application - Part 2 Medical History                                                       Oregon
753 MA    2004/08   Massachusetts Notice of Insurance Information Practices (Pre Notice)          757 OR    2004/07   Oregon HIV Antibody/Antigen Consent and Testing Form

754 MA    2004/08
                    Massachusetts Simplified Issue Life Insurance Application Supplement -                                              Pennsylvania
                    Additional Other Proposed Insured
                                                                                                  701 PA    2004/06   Pennsylvania Life Insurance Application - Part 1
                    Massachusetts Simplified Issue Life Insurance Application Supplement -
755 MA    2004/08
                    Additional Owners                                                             702 PA    2004/10   Pennsylvania Life Insurance Application - Part 2 Med History
                    Massachusetts Simplified Issue Life Insurance Application Supplement -                            Pennsylvania Life Insurance Application Supplement - Additional Other
756 MA    2004/08                                                                                 754 PA    2004/06
                    Additional Beneficiaries                                                                          Proposed Insured
757 MA    2004/11   Massachusetts HIV Antibody/Antigen Consent and Testing Form                   755 PA    2004/06   Pennsylvania Life Insurance Application Supplement - Additional Owners

760 MA    2007/03   Massachusetts Important Notice Regarding Replacement                          756 PA    2004/06   Pennsylvania Life Insurance Application Supplement - Additional Beneficiaries

761 MA    2004/08
                    Massachusetts Simplified Issue Policy Effective Date Supplement - Date of                                           Rhode Island
                    Policy Application
                                                                                                  766 RI    2007/03   Rhode Island Life Product Comparison Form
                    Massachusetts Simplified Issue Policy Effective Date Supplement - Date of
762 MA    2004/08
                    Policy Delivery                                                                                                          Texas
                    Massachusetts Simplified Issue Policy Effective Date Supplement - Date        757 TX    2004/11   Texas HIV Antibody/Antigen Consent and Testing Form
763 MA    2004/08
                    Policy Issued
                                                                                                  759 TX    2008/02   Texas Important Notice: Replacement of Life Insurance or Annuities
                    Massachusetts Life Insurance Application - Part 2 Medical History - Medical
768 MA    2004/03
                    Condition Details / Additional Care Providers                                                                          Vermont
                                        Michigan                                                  702 VT    2004/10   Vermont Life Insurance Application - Part 2 Medical History

757 MI    2004/12   Michigan HIV Antibody/Antigen Consent and Testing Form                        751 VT    2005/11   Vermont Authorization to Obtain and Disclose Information

                                        Minnesota                                                 757 VT    2004/07   Vermont HIV Antibody / Antigen Consent and Testing Form

701 MN    2004/08   MN Life Insurance Application - Part 1                                        760 VT    2005/11   Vermont Important Notice Regarding Replacement

702 MN    2005/02   MN Life Insurance Application - Part 2 Medical History                                            Vermont Life Insurance Application - Part 2 Medical History Medical
                                                                                                  768 VT    2004/10
                                                                                                                      Condition Details / Additional Care Providers
751 MN    2005/01   Minnesota Authorization to Obtain and Disclose Information
                                                                                                                                            Virginia
                    MN Life Insurance Application Supplement - Additional Other Proposed
754 MN    2004/08
                    Insured                                                                       655 VA    2010/12   Virginia Group Health Insurance - Medical History Form

755 MN    2004/08   MN Life Insurance Application Supplement - Additional Owners                  701VA     2004/06   Virginia Life Insurance Application - Part 1

756 MN    2004/08   MN Life Insurance Application Supplement - Additional Beneficiaries           751VA     2004/12   Virginia Authorization to Obtain and Disclose Information

767 MN    2005/01   Minnesota Temporary Insurance Agreement                                                           Virginia Life Insurance Application Supplement - Additional Other Proposed
                                                                                                  754VA     2004/06
                                                                                                                      Insured
                                         Missouri
                                                                                                  755VA     2004/06   Virginia Life Insurance Application Supplement - Additional Owners
701 MO    2004/08   Missouri Life Insurance Application - Part 1
                                                                                                  756VA     2004/06   Virginia Life Insurance Application Supplement - Additional Beneficiaries
                    Missouri Life Insurance Application Supplement - Additional Other Proposed
754 MO    2004/08
                    Insured                                                                       767VA     2004/12   Virginia Temporary Insurance Agreement

755 MO    2004/08   Missouri Life Insurance Application Supplement - Additional Owners                                                   Washington
756 MO    2004/08   Missouri Life Insurance Application Supplement - Additional Beneficiaries     757 WA    2010/05   Washington HIV Antibody/Antigen Consent and Testing Form

761 MO    2004/08   Missouri Policy Effective Date Supplement - Date of Policy Application        760 WA    2005/09   Washington Important Notice Regarding Replacement
762 MO    2004/08   Missouri Policy Effective Date Supplement - Date of Policy Delivery                                                 West Virginia
763 MO    2004/08   Missouri Policy Effective Date Supplement - Date Policy Issued                757 WV    2004/07   West Virginia HIV Antibody/Antigen Consent and Testing Form

767 MO    2004/11   Missouri Temporary Insurance Agreement                                                                                Wisconsin
                                    New Hampshire                                                 702 WI    2004/10   Wisconsin Life Insurance Application - Part 2 Medical History

757 NH    2004/07   New Hampshire HIV Antibody/Antigen Consent and Testing Form                   757 WI    2005/03   Wisconsin HIV Antibody / Antigen Consent and Testing Form

                                        New York                                                  767 WI    2004/07   Wisconsin Temporary Insurance Agreement

751 NY    2005/11   New York Authorization to Obtain and Disclose Information                                         Wisconsin Life Insurance Application - Part 2 Medical History Medical
                                                                                                  768 WI    2004/10
                                                                                                                      Condition Details / Additional Care Providers
753 NY    2005/11   New York Notice of Insurance Information Practices (Pre Notice)

757 NY    2005/11   New York HIV Antibody/Antigen Consent and Testing Form
                    New York Important Notice Regarding Replacement or Change of Life
760 NY    2007/03
                    Insurance Policies or Annuity Contracts
                    New York Disclosure Statement Regarding Replacement of Life Insurance
775 NY    2007/03
                    Policies or Annuity Contracts
776 NY    2007/03   New York Definition of Replacement

960 NY    2007/03   New York Disclosure Statement Annuity to Annuity Replacements Only

                                    North Carolina
751 NC    2006/02   North Carolina Authorization to Obtain and Disclose Information

767 NC    2004/12   North Carolina Temporary Insurance Agreement




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                   ACORD Forms Index (rev. 09-28-2012)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                    Page 12 of 12

				
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