ACORD Forms Index ACORD Forms Index by gabyion

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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               2009/02   Property Loss Notice                                                      82         2007/06   Watercraft Application
2               2009/02   Automobile Loss Notice                                                    83         2008/11   Personal Umbrella Application Section
3               2009/02   General Liability Notice of Occur/Claim                                   88         2009/02   Personal Insurance Application - Applicant Information Section
4               2009/01   Workers Compensation - First Report of Injury or Illness                  89         2009/02   Residential Section
5               2009/05   Aircraft Loss Notice                                                      91         3/93a     Good Student Driver Training
6               2009/05   Aviation Witness / Passenger Schedule                                     92         2/95      Medical Statement
7               2009/05   Aviation Injured Schedule                                                 93         2004/10   Young Driver Questionnaire
11              2/95      Auto Accident Information Form                                            99         2009/02   Accidents / Convictions Schedule
12              2/95      Exchange of Information Form                                              101        2008/01   Additional Remarks Schedule
13              2/95      Witness Card                                                                                   Personal Auto Application Schedule - Additional Resident and
                                                                                                    103        2008/01
                                                                                                                         Driver Information Section
20              2009/05   Certificate of Aviation Liability Insurance
                                                                                                    125        2009/05   Commercial Insurance Application - Applicant Information Section
21              2009/05   Certificate of Aircraft Insurance
                                                                                                    126        2007/05   Commercial General Liability Section
22              2007/02   Intermodal Interchange Certificate of Insurance
                                                                                                    127        2009/01   Business Auto Section
23              2007/05   Automobile Certificate of Insurance
                                                                                                    128        2008/05   Garage and Dealers Section
24              1/95      Certificate of Property Insurance
                                                                                                    129        2009/01   Vehicle Schedule
25              2009/01   Certificate of Liability Insurance
                                                                                                    130        2007/11   Workers Compensation Application
26              2002/01   Policy Certification Log
                                                                                                    131        2009/02   Umbrella Section
27              2006/07   Evidence of Property Insurance
                                                                                                    132        2008/09   Truckers / Motor Carriers Section
28              2006/07   Evidence of Commercial Property Insurance
                                                                                                    133        2007/11   Workers Compensation Insurance Plan - Assigned Risk Section
35              1/97      Cancellation Request/Policy Release
                                                                                                    139        2004/03   Statement/Schedule of Values
36              2007/01   Agent/Broker of Record Change
                                                                                                    140        2007/09   Property Section
37              2008/01   Statement of No Loss
                                                                                                    141 C      2007/06   Crime Section 2000
42              2009/07   Residential Property Replacement Cost
                                                                                                    143        2004/01   Transportation Section
45              2009/04   Additional Interest Schedule
                                                                                                    144        2007/07   Glass And Sign Supplement
50              2007/02   Automobile Insurance ID Card
                                                                                                    145        2004/03   Accounts Receivable/Valuable Papers
50 WM           2007/03   Automobile Insurance ID Card (with Watermark)
                                                                                                    146        2007/02   Equipment Floater Section
54              1/97      Financial Responsibility Form
                                                                                                    147        2001/02   Installation/Builder's Risk Section
57              1/97      Financial Responsibility Form - Cancellation
                                                                                                    148        2000/02   Electronic Data Processing Section
58              2007/11   Notice of Cancellation or Termination of Policy
                                                                                                    149        2007/10   Dealers Section
60              2008/11   Flood Insurance Selection / Rejection
                                                                                                    151        2008/01   Miscellaneous Crime Coverage Section
60 US           2008/02   Insurance Supplement - Notice - Offer of Terrorism Coverage
                                                                                                    155 BM     2004/12   Boiler & Machinery Section 2002
                          Insurance Supplement - Standard Fire Policy Only
62 US           2008/02                                                                             159        2004/03   Schedule of Insurance
                          Notice - Offer of Terrorism Coverage
63              2009/07   Fraud Statements                                                          160        2009/05   Business Owners Application
                          Insurance Supplement - Workers' Compensation Only                         163        2000/11   Commercial Auto Driver Information Schedule
64 US           2008/02
                          Notice - Offer of Terrorism Coverage
                                                                                                    175        2009/01   Commercial Policy Change Request
70              2009/06   Personal Policy Change Request (Except Auto)
                                                                                                    180        1/97      Errors and Omissions Section - Electronic Data Processors, etc.
71              2009/06   Personal Auto Policy Change Request
                                                                                                    185        2007/05   Restaurant/Tavern Supplement
72              2007/10   Certification of Mobile Home Tie-downs Supplement
                                                                                                    186        2009/03   Contractors Supplement
73              2009/07   Solid Fuel Questionnaire
                                                                                                    187        2003/07   Professional Liability Supplement
74              2008/07   Residence Based Business
                                                                                                    188        2003/02   Employment Related Practices Liability Section
75              2007/01   Insurance Binder
                                                                                                    190        2007/05   Supplemental Property Application
76              9/93      Binder Log
81              2005/08   Personal Inland Marine Application                                        193        2001/02   Open Cargo Section


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                       ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                          Page 1 of 10
                                                                                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
194       2009/03   Truckers / Motor Carrier Supplement                                          815       2009/02   International Liability Exposure Supplement
195       10/96     Design Professional's Individual Property Survey                             816       2005/06   International Property Exposure Supplement
196       2008/03   Medical Professional Liability Insurance Application                         817       2007/08   P&C Producer Appointment Form - Appointment Section
199       1/99      Application Supplement - Undertaking                                         818       2007/08   P&C Producer Appointment Form - Background Questions
200       3/93      Producer Account                                                                                 P&C Producer Appointment Form - Additional Appointment or
                                                                                                 819       2007/08
                                                                                                                     Termination
201       3/93      Producer Account Discrepancy Notice
                                                                                                 822       2009/07   Driver Work / School Address Information Supplement
210       2001/05   Yacht Section
                                                                                                 823       2009/09   Additional Premises Information Schedule
225       1/98      Policyholder's Report
                                                                                                                     Professional / Specialty Insurance Application - For Use in
226       3/93      Statement of Premium Adjustment                                              825       2008/01
                                                                                                                     Management, Executive & Professional Lines - Applicant Section
275       2009/05   Aviation Insurance Binder                                                    827       2008/01   Employment Practices Liability Insurance Section
276       2009/05   Aircraft Insurance Binder                                                    828       2008/07   Fiduciary Liability Coverage Section
301       2008/06   National Flood Insurance Program - Flood Insurance Application               829       2009/05   Forms and Endorsements Schedule
302       2008/06   NFIP - Flood Insurance General Change Endorsement                            830       2008/11   Property Insurance Card
303       2008/06   NFIP - Flood Insurance Preferred Risk Policy Application
304       2008/06   NFIP - Flood Insurance Cancellation / Nullification
325       2009/06   Aviation Insurance Application - Applicant Information Section
326       2006/04   Airport Property Supplement
327       2006/04   Airport and FBO Liability Section
328       2006/04   Private Hangar Liability Section
329       2009/06   Aviation Products Liability
330       2009/04   Aircraft Section
331       2006/06   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       2009/06   Pilot Experience Change Request
342       2009/06   Hangar Change Request
350 WM    2009/06   Watermark Paper - 20 # ID Card Stock (4-part perforation)
360 WM    2009/06   Watermark Paper - 32 # ID Card Stock (4-part perforation)
370 WM              Watermark Paper - 32 # ID Card Stock (non-perforated)
401       2007/09   Agriculture Application
402       2009/03   Agriculture Property Section
403       2007/09   Agriculture Prop Sect - Scheduled/Unscheduled Personal Property
404       2007/09   Agriculture Liability Section
405       2007/09   Agriculture Premises Diagram
                    Agriculture Supplement - Unscheduled Farm Personal Property
406       2007/09
                    Inventory Form
407       2007/09   Livestock Mortality Section
408       2007/09   Equine Liability Supplement
410       2004/04   Small Farm/Ranch Application
501       2004/07   Surety Report of Execution
610       2009/04   Premium Payment Supplement
801       2002/01   Railroad Protective Liability Supplement
802       2007/07   Hotel/Motel Supplement
807       2009/02   Directors & Officers Liability Section
808       2009/03   P&C Agency Appointment Form
                    Business Income / Extra Expense / Rental Value
810       2007/07
                    Supplement to Property Section
811       2007/07   Value Reporting Information Supplement to Property Section
812       2006/02   Agency Questionnaire
813       2005/03   Request for Proof of Property Insurance

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 2 of 10
                                                                               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                                                                                             Colorado
50 AL     2007/10   Alabama Insurance Identification Card                                           50 CO      2007/03   Colorado Insurance Identification Card
62 AL     5/98      Alabama Insurance Application Supplement                                        61 CO      2009/02   Colorado Auto Supplement - Summary of Coverages
90 AL     2004/04   Alabama Personal Automobile Application                                         62 CO      2/97      Colorado Personal Property Supplement - Coverage Disclosure
137 AL    2004/04   Alabama Commercial Auto                                                                              Colorado Auto Supplement - Colorado Offer of Medical Payments
                                                                                                    64 CO      2009/01
                                                                                                                         Coverage
138 AL    2004/04   Alabama Garage and Dealers
                                                                                                    90 CO      2009/01   Colorado Personal Automobile Application Section
                                           Alaska
                                                                                                    137 CO     2008/01   Colorado Commercial Auto
61 AK     7/97      Alaska Auto Supplement - UM/UIM Coverage Selection
                                                                                                    138 CO     2008/01   Colorado Garage and Dealers
62 AK     2/98      Alaska Auto Supplement - Exclusion of Named Drivers
                                                                                                    171 CO     2006/01   Colorado Rejection of Coverage by Corporate Officers
90 AK     2005/08   Alaska Personal Auto Application
                                                                                                                                            Connecticut
137 AK    2005/08   Alaska Commercial Auto
                                                                                                                         Notice of Information Practices (Privacy) for states
138 AK    2005/08   Alaska Garage and Dealers                                                       38         2008/04
                                                                                                                         of CA / CT / GA / IL / NV / NJ / RI / VA / WA
171 AK    6/98      Alaska Petition For Executive Officer Waiver                                    50 CT      2009/01   Connecticut Insurance Identification Card

                                         Arkansas                                                   61 CT      2004/11   Connecticut Auto Supplement - UM Coverage
50 AR     2007/10   Arkansas Proof of Insurance Card                                                66 CT      2006/06   Connecticut FAIR Plan Application for Property/Liability Insurance
61 AR     2002/03   Arkansas Auto Supplement UM/UIM Coverage                                        90 CT      2005/11   Connecticut Personal Automobile Application
                    Arkansas Property Supplement - Declination of                                   137 CT     2005/11   Connecticut Commercial Auto
67 AR     2000/02
                    Residential Earthquake Coverage
                                                                                                    138 CT     2005/11   Connecticut Garage and Dealers
90 AR     2008/04   Arkansas Personal Auto Application Section
                                                                                                    171 CT     2006/08   Connecticut Workers' Comp. Comm. - Coverage Election by
137 AR    2004/05   Arkansas Commercial Auto                                                                             Employee Who Is an Officer of a Corporation, Manager of an
                                                                                                                         LLC, or Member of a Multiple-Member LLC
138 AR    2000/10   Arkansas Garage and Dealers
                                                                                                    172 CT     2006/08   Connecticut Workers' Comp. Comm. - Coverage Election by
                                          Arizona                                                                        Employees who are Members of a Partnership
38 AZ     2003/10   Arizona Notice of Information Practices (Privacy)                                                    Connecticut Workers' Comp. Comm. - Coverage Election by Sole
                                                                                                    173 CT     2006/08
                                                                                                                         Proprietor or Single-Member LLC
50 AZ     2007/11   Arizona Insurance Identification Card
                                                                                                                                              Delaware
61 AZ     2001/02   Arizona Auto Supplement UM/UIM Coverage Selection
                                                                                                                         Delaware Personal Insurance Supplement
90 AZ     2006/04   Arizona Personal Automobile Application                                         38 DE      2008/04
                                                                                                                         Notice of Information Practices (Privacy)
137 AZ    2006/04   Arizona Commercial Auto                                                         50 WM      2007/03   Automobile Insurance ID Card (with Watermark)
138 AZ    2006/04   Arizona Garage and Dealers                                                                           DE Auto Supplement, DE Motorist's Protection Act - Required
                                                                                                    61 DE      2006/10
                                                                                                                         Statement to Policyholders
                                        California
                                                                                                    62 DE      2004/10   DE Auto Supplement, PIP Deductible Options
                    Notice of Information Practices (Privacy) for states
38        2008/04                                                                                                        Insurance Placement Facility of Delaware
                    of CA / CT / GA / IL / NV / NJ / RI / VA / WA                                   64 DE      2006/08
                                                                                                                         Basic Property Insurance Application
50 CA     2004/07   California Insurance Identification Card
                                                                                                    65
51 CA     2004/07   California Evidence of Liability Insurance                                                 2006/08   FAIR Plan Supplementary Questionnaire
                                                                                                    PA/DE/WV
52 CA     2007/07   California Fleet Auto Insurance Identification Card                             90 DE      2008/04   Delaware Personal Auto Application Section
                    California Auto Supplement - Mandatory UM Bodily Injury /                       137 DE     2006/07   Delaware Commercial Auto
61 CA     2008/03
                    Property Damage Coverage Offer
                                                                                                    138 DE     2006/07   Delaware Garage and Dealers
64 CA     2004/02   California Insurance Supplement - Agency Language
                                                                                                    171 DE     2006/01   Delaware Executive Officer(s) Exclusion
65 CA     2004/07   California Insurance Supplement - Race, National Origin, Gender
                                                                                                                                      District of Columbia
66 CA     2/98      California Offer of Earthquake Coverage
                                                                                                                         Application to District of Columbia Property Insurance Facility for
67 CA     2005/03   California Residential Property Insurance Disclosure                            64 DC      2009/06
                                                                                                                         Basic Property Insurance
                    California Scheduled Personal Property Loss Computation                                              District of Columbia Property Insurance Facility - Essential
68 CA     2001/03                                                                                   66 DC      2005/12
                    Disclosure                                                                                           Homeowners Insurance Inspection and Placement Application p. 1
90 CA     2007/04   California Personal Auto Application                                                                 District of Columbia Property Insurance Facility - Essential
                                                                                                    67 DC      2005/12
                                                                                                                         Homeowners Insurance Inspection and Placement Application p. 2
137 CA    2007/01   California Commercial Auto
                                                                                                    90 DC      2006/04   District of Columbia Personal Auto Application
138 CA    2007/01   California Garage and Dealers
                                                                                                    137 DC     2007/07   District of Columbia Commercial Auto
177 CA    2001/03   California Auto Body Repair Consumer Bill of Rights
                                                                                                    138 DC     2006/04   District of Columbia Garage and Dealers
                    California FAIR Plan Property Insurance - Application for Property
855 CA    2008/06
                    Insurance
                    California FAIR Plan Property Insurance - Business Owners
856 CA    2004/07
                    Application
                    California Earthquake Authority - Application for Earthquake
857 CA    2009/05
                    Insurance
860 CA    2004/12   California Auto Supplement - Driver Self Certification
861 CA    2006/07   California Residential Property Insurance Bill of Rights




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                      ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                         Page 3 of 10
                                                                                  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
                                           Florida                                                                                           Illinois
50 FL     2009/07   Florida Personal Auto ID Card (two part)                                                          Notice of Information Practices (Privacy) for states
                                                                                                  38        2008/04
                                                                                                                      of CA / CT / GA / IL / NV / NJ / RI / VA / WA
51 FL     2009/07   Florida Commercial Auto ID Card
                                                                                                  50 IL     2007/03   Illinois Insurance Identification Card
61 FL     2008/06   Florida Auto Supplement - Rejection/Election of UM Coverage
                                                                                                  61 IL     2003/03   Illinois Auto Supplement - UM/UIM
62 FL     2008/06   Florida Auto Supplement - Personal Injury Protection Options
                                                                                                                      Illinois Property Supplement - Notice of Availability of
                    Florida Auto Supplement - Notice to Policyholders - Florida                   62 IL     2007/08
64 FL     2008/06                                                                                                     Earthquake Insurance
                    Notification of Availability of Uninsured Motorist Coverage
                                                                                                                      Mine Subsidence Property Insurance Supplement
65 FL     2007/08   Florida Residential Property Supplement                                       67        2008/04
                                                                                                                      Illinois, Indiana, Kentucky, West Virginia
                    Florida Insurance Supplement                                                  69 IL     2007/02   Illinois FAIR Plan - App for Homeowners & Dwelling Property
66 FL     2001/08
                    Credit Report Disclosure Information
                                                                                                  90 IL     2003/10   Illinois Personal Auto Application
67 FL     7/94      Florida Homeowners Supplement
                                                                                                  137 IL    2003/03   Illinois Commercial Auto
                    Citizens Property Insurance Corporation
68 FL     2004/09                                                                                 138 IL    2003/03   Illinois Garage and Dealers
                    Residential - Dwelling Wind Only
                    Citizens Property Insurance Corporation                                       171 IL    2005/06   Illinois FAIR Plan Application for Commercial Property Insurance
69 FL     2004/09
                    Wind Only Supplemental Residential - Application Schedule
                                                                                                                                             Indiana
90 FL     2008/05   Florida Personal Auto Application
                                                                                                  50 IN     2007/11   Indiana Insurance Identification Card
130 FL    2002/07   Florida Workers Compensation Application
                                                                                                                      Mine Subsidence Property Insurance Supplement
133 FL    2007/07   Florida Workers Comp. Addendum to ACORD 130 FL                                67        2008/04
                                                                                                                      Illinois, Indiana, Kentucky, West Virginia
                    Florida Workers Comp. Instructions for                                        90 IN     2009/09   Indiana Personal Auto Application
134 FL    2009/07
                    Completing ACORD 130 FL and 133 FL
                                                                                                  137 IN    2009/09   Indiana Commercial Auto
137 FL    2009/08   Florida Commercial Auto
                                                                                                  138 IN    2009/09   Indiana Garage and Dealers
138 FL    2009/08   Florida Garage and Dealers
                                                                                                                                               Iowa
171 FL    2004/04   Florida Notice of Election of Coverage
                                                                                                  50 IA     2007/08   Iowa Financial Responsibility Card
172 FL    2007/08   Florida Revocation of Election to be Exempt
                                                                                                  61 IA     2002/02   Iowa Auto Supplement - UM/UIM Offer/Rejection
173 FL    2007/08   Florida Notice of Election to be Exempt
                                                                                                  62 IA     2/98      Iowa Auto Supplement - Notice Regarding UM/UIM Coverage
174 FL    2007/08   Florida Revocation of Election of Coverage
                                                                                                  64 IA     4/98      Iowa Auto Supplement - UM/UIM Stacking Coverage Notice
175 FL    3/97      Florida Workers Compensation Monthly Change Sheet
                                                                                                  65 IA     2008/01   Iowa Auto Supplement - Aftermarket Crash Parts
                    Citizens Property Insurance Corporation
220 FL    2003/08                                                                                                     Iowa Personal Insurance Supplement
                    Commercial and Commercial - Residential Wind Only                             66 IA     2006/07
                                                                                                                      Disclosure Use of Claims History
                    Citizens Property Ins Corp, Wind Only - Supplemental Application
221 FL    2002/07                                                                                 90 IA     2006/07   Iowa Personal Auto Application
                    Schedule Commercial and Commercial - Residential

                                          Georgia                                                 137 IA    2007/01   Iowa Commercial Auto
                    Notice of Information Practices (Privacy) for states                          138 IA    2007/01   Iowa Garage and Dealers
38        2008/04
                    of CA / CT / GA / IL / NV / NJ / RI / VA / WA
                                                                                                                                             Kansas
50 GA     2008/11   Georgia Insurance Policy Information Card
                                                                                                                      Kansas Personal Insurance Supplement - Notice of Insurance
51 GA     2004/07   Georgia Fleet Policy Information Card                                         38 KS     2005/03
                                                                                                                      Information Practices
                    Georgia Auto Supplement - Georgia Auto Disclosure Form,                       90 KS     2008/06   Kansas Personal Auto Application
64 GA     2009/01
                    Notice to Policyholders, Uninsured Motorist Coverage Selection
                                                                                                  137 KS    2008/07   Kansas Commercial Auto
90 GA     2009/01   Georgia Personal Automobile Application Section
                                                                                                  138 KS    2008/07   Kansas Garage and Dealers
137 GA    2009/02   Georgia Commercial Auto
                                                                                                  171 KS    2005/11   Kansas Elec. of Individual, Partner or Self-Employed Individual
138 GA    2006/11   Georgia Garage and Dealers
                                                                                                  172 KS    2005/11   Kansas Cancel. of Elec. of Individual, Partner or Self-Employed Ind.
171 GA    2001/03   Georgia Workers' Comp - Corporate Officer Rejection
                                                                                                  173 KS    2005/11   Kansas Cancellation of Election Not to Accept Coverage
                                           Hawaii
                                                                                                  174 KS    2005/11   Kansas Election Not to Accept Coverage
50 HI     2008/01   Hawaii Auto ID Card
                                                                                                  176 KS    2005/11   Kansas Election of Employer to Cover Employees
60 HI     2005/01   Hawaii Auto Supplement - UM/UIM/PIP
                                                                                                  177 KS    2005/11   Kansas Election of Coverage for Volunteer Workers
90 HI     2005/01   Hawaii Personal Automobile Application
                                                                                                  178 KS    2005/11   Kansas Cancellation of Election of Employer to Cover Employees
94 HI     2001/03   Hawaii Vehicle Inspection Report Supplement
                                                                                                  179 KS    2005/11   Kansas Cancel. of Election of Coverage for Volunteer Workers
137 HI    2005/01   Hawaii Commercial Auto
                                                                                                  180 KS    2005/11   Kansas Election of Coverage for Persons Performing Public Service
138 HI    2005/01   Hawaii Garage and Dealers
                                                                                                                      Kansas Cancellation of Election of Coverage for Persons
                                                                                                  181 KS    2005/11
                                            Idaho                                                                     Performing Public Service
50 ID     2007/10   State of Idaho Liability Insurance Identification Card                        182 KS    2001/05   Kansas Election of a Noncompensated Volunteer to be Covered
                    Idaho Auto Supplement - Idaho Uninsured Motorist and                                              Kansas Cancellation of Election of a Noncompensated Volunteer
61 ID     2009/01                                                                                 183 KS    2001/05
                    Underinsured Motorist Disclosure Statement                                                        to be Covered
90 ID     2009/01   Idaho Personal Automobile Application Section
137 ID    2009/01   Idaho Commercial Auto
138 ID    2009/01   Idaho Garage and Dealers




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                    ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                       Page 4 of 10
                                                                                  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
                                            Kentucky                                                                                  Massachusetts (continued)
50 KY         2006/01   Commonwealth of Kentucky Proof of Insurance (2 part)                                                  Massachusetts Property Insurance Underwriting Association -
                                                                                                      66 MA         2005/01   Inspection Notice, Credit Reporting Notice and Instructions for
64 KY         2009/01   Kentucky FAIR Plan Homeowners Application                                                             Completing Dwelling Fire Application ACORD 65 MA
65 KY         2009/01   Kentucky FAIR Plan Dwelling Fire Application                                  90 MA         2008/03   Application for Massachusetts Motor Vehicle Insurance
66 KY         2009/01   Kentucky FAIR Plan Farm Fire Application                                      95 MA         2007/08   Massachusetts Renewal Application (Statement of Facts)
                        Mine Subsidence Property Insurance Supplement                                 137 MA        2006/05   Massachusetts Commercial Auto
67            2008/04
                        Illinois, Indiana, Kentucky, West Virginia
                                                                                                      138 MA        2006/05    Massachusetts Garage and Dealers
68 KY         2009/01   Kentucky FAIR Plan Commercial Fire Application
                                                                                                                                                  Michigan
69 KY         2009/01   Kentucky FAIR Plan Woodstove Questionnaire
                                                                                                      50 MI         2007/12   Michigan Insurance Auto ID Card
90 KY         2006/04   Kentucky Personal Automobile Application
                                                                                                      50 MI (set)   2007/12   Michigan Insurance Auto ID Card (2 part)
137 KY        2006/04   Kentucky Commercial Auto
                                                                                                      62 MI         2000/01   Michigan Collision Insurance Options Notice
138 KY        2000/09   Kentucky Garage and Dealers
                                                                                                      64 MI         2000/10   Michigan Basic Property Insurance Assn Insurance Application
                                            Louisiana
                                                                                                      90 MI         2009/01   Michigan Personal Automobile Application Section
50 LA         2008/03   Louisiana Auto ID Card (2 part)
                                                                                                      133 MI        2009/02   Michigan Application for Workers' Compensation Insurance
60 LA         4/98      Louisiana Dwelling Supplement - Loss Settlement DWG1
                                                                                                      137 MI        2000/09   Michigan Commercial Auto
61 LA         2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO4)
                                                                                                      138 MI        4/96      Michigan Garage and Dealers
62 LA         4/98      Louisiana Commercial Property Supplement
                                                                                                                              Michigan Automobile Insurance Placement Facility Supplement to
64 LA         2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO2 & 3)                   139 MI        2004/07   ACORD App. - Application for Commercial, Public Automobiles
                                                                                                                              and Corporately Owned Vehicles
65 LA         2001/02   Louisiana Homeowners Supplement - Loss Settlement (HO6)
                                                                                                      171 MI        2005/01   Michigan Notice of Election
66 LA         4/98      Louisiana Dwelling Supplement - Loss Settlement DWG2 & 3
                                                                                                      172 MI        4/96      Michigan App for Exclusion of Partner(s), Spouse, Child or Parent
67 LA         5/98      Louisiana Certification of Mobile Home Tie Downs
                                                                                                      173 MI        2000/09   Michigan WC Placement Facility Specific Person Exclusion
68 LA         4/98      Louisiana Plan Services Application for Insurance
                                                                                                                                                  Minnesota
90 LA         2009/01   Louisiana Personal Auto Application
                                                                                                      38 MN         2005/08   Minnesota Notice of Information Practices (Privacy)
137 LA        2009/01   Louisiana Commercial Auto
                                                                                                      62 MN         2000/01   Minnesota Auto Supplement
138 LA        2009/01   Louisiana Garage and Dealers
                                                                                                      65 MN         2005/06   Minnesota Guaranty Association Notice
861 LA        2005/07   Louisiana Auto Supplement - Active Military Personnel Affidavit
                                                                                                      90 MN         2006/08   Minnesota Personal Automobile Application
862 LA        2009/06   Louisiana Property Supplement - Hurricane Loss Mitigation Survey
                                                                                                      137 MN        2006/08   Minnesota Commercial Auto
                                              Maine
                                                                                                      138 MN        2006/08   Minnesota Garage and Dealers
50 ME         2007/08   Maine Motor Vehicle Insurance Identification Card
                                                                                                                                                 Mississippi
90 ME         2005/08   Maine Personal Auto Application
                                                                                                      50 MS         2008/01   Mississippi Auto Insurance ID Card
137 ME        2000/09   Maine Commercial Auto
                                                                                                      61 MS         2006/01   Mississippi Auto Supplement - Non-Stacking UM Insurance
138 ME        2000/09   Maine Garage and Dealers
                                                                                                      90 MS         2004/09   Mississippi Personal Auto Application
                                            Maryland
                                                                                                      137 MS        2004/09   Mississippi Commercial Auto
39 MD         2003/05   Maryland Application Supp Notice of Intent to Use Credit History
                                                                                                      138 MS        2004/09   Mississippi Garage and Dealers
62 MD         1/98      Maryland Commercial Auto Supplement
                                                                                                      139 MS        2/99      Mississippi Statement/Schedule of Values
                        Maryland Property Insurance Availability Program
64 MD (set)   2007/01
                        Essential Property Insurance Inspection and Placement (4 part)                                                             Missouri
                        Maryland Property Insurance Availability Program - Essential                  50 MO (set)   2007/05   Missouri Auto Insurance ID Card (2 part)
65 MD         2005/12   Homeowners Insurance Inspection and Placement (p.1 of 2)
                                                                                                                              Missouri Property Supplement - Notice of Availability of
                        Maryland Property Insurance Availability Program - Essential                  62 MO         2007/08
66 MD         2005/12                                                                                                         Earthquake Insurance
                        Homeowners Insurance Inspection and Placement (p.2 of 2)
                                                                                                      67 MO         2009/06   Missouri FAIR Plan Insurance Application
                        Maryland Personal Auto Supplement - Mandatory Offer of
67 MD         2005/01   Increased Liability Coverage for Claims of Family Members,                    90 MO         2008/08   Missouri Personal Auto Application
                        Mandatory PIP Waiver, and Mandatory UM Coverage Waiver
                                                                                                      137 MO        2008/08   Missouri Commercial Auto
                        Maryland Personal Property Supplement - Statement Regarding
68 MD         2006/10                                                                                 138 MO        2008/08   Missouri Garage and Dealers
                        Flood Insurance
69 MD         2007/01   Maryland Insurance Supplement - Notice of Underwriting Period
90 MD         2009/01   Maryland Personal Auto Application Section
137 MD        2009/01   Maryland Commercial Auto
138 MD        2009/01   Maryland Garage and Dealers
                        Maryland Personal Property Supplement - Loss from Water and
851 MD        2008/11
                        Sewer Backup

                                        Massachusetts
                        Massachusetts Property Insurance Underwriting Association
60 MA         2001/05
                        Application for Homeowners Insurance
                        Massachusetts Property Insurance Underwriting Association
61 MA         2001/05
                        Instructions to Complete Homeowners Application ACORD 60 MA
                        Massachusetts Residential Property Liability Supplement
64 MA         2/97
                        Lead Poisoning Liability Disclosure Notice
                        Massachusetts Property Insurance Underwriting Association -
65 MA         2005/01
                        Application for Dwelling Fire Insurance Inspection and Placement

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                           ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                              Page 5 of 10
                                                                            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
                                         Montana                                                                                      New Mexico
60 MT     2003/09   Montana Application Supplement - Refusal to Renew                           60 NM     2003/01   New Mexico Confidential Abuse Disclosure
90 MT     2009/08   Montana Personal Auto Application                                                               New Mexico Auto Supplement - UM Coverage Selection/Rejection
                                                                                                61 NM     2005/04
                                                                                                                    and Rejection Of Stacked UM Coverage
                    Montana State Compensation Insurance Fund
133 MT    8/98                                                                                  90 NM     2006/02   New Mexico Personal Auto Application
                    Worker’s Compensation Application Supplement
137 MT    2009/08   Montana Commercial Auto                                                     137 NM    2005/04   New Mexico Commercial Auto
138 MT    2009/08   Montana Garage and Dealers                                                  138 NM    2005/01   New Mexico Garage and Dealers

                                         Nebraska                                               171 NM    2004/10   New Mexico Executive Employee Affirmative Election Form
50 NE     2007/01   Nebraska Auto Liability Insurance Identification Card                       172 NM    2004/10   New Mexico Election to Accept
90 NE     2003/12   Nebraska Personal Auto Application                                          173 NM    2004/10   New Mexico Revocation
137 NE    2001/10   Nebraska Commercial Auto                                                    174 NM    2004/10   NM Limited Liability Company Member Affirmative Election Form
138 NE    8/97      Nebraska Garage and Dealers                                                                                         New York
                                          Nevada                                                38 NY     2005/04
                                                                                                                    New York Personal Insurance Supplement - Notice of Information
                                                                                                                    Practices
                    Notice of Information Practices (Privacy) for states
38        2008/04                                                                               60 NY     2008/03   New York Homeowners Supplement
                    of CA / CT / GA / IL / NV / NJ / RI / VA / WA
51 NV     2008/11   Nevada Temporary Insurance Identification Card                              61 NY     3/94      New York Auto Supplement (Optional Basic Econ Loss)
                    Nevada Auto Supplement, Mandatory Offer of Medical Payments                 62 NY     2009/04   New York Application For Dwelling Insurance - NYPIUA
61 NV     2002/12
                    Coverage and Uninsured Motorists Coverage
                                                                                                64 NY     2008/06   New York Auto Supplement - Supp UM/UIM Insurance Coverage
62 NV     2001/05   Nevada Umbrella Supplement
                                                                                                65 NY     2003/01   New York Auto Supplement - Spousal Liability Coverage
90 NV     2001/03   Nevada Personal Auto Application
                                                                                                67 NY     2009/04   Instructions for Completion of ACORD 62 NY
137 NV    2001/11   Nevada Commercial Auto
                                                                                                68 NY     2002/01   New York Liability Supplement - "Claims-Made Policy"
138 NV    3/96      Nevada Garage and Dealers
                                                                                                                    New York Personal Property Supplement - Important Flood
                                                                                                69 NY     2008/08
                                    New Hampshire                                                                   Insurance Notice
90 NH     2006/05   New Hampshire Personal Auto Application                                     70 NY     2006/04   NYPIUA Instructions for Completing ACORD 177 NY
137 NH    2006/05   New Hampshire Commercial Auto                                               90 NY     2005/04   New York Personal Auto Application
138 NH    2006/05   New Hampshire Garage and Dealers                                            137 NY    2003/11   New York Commercial Auto

                                      New Jersey                                                138 NY    2003/11   New York Garage and Dealers
                    Notice of Information Practices (Privacy) for states                        171 NY    10/96     New York Notice of Election of a Corporation
38        2008/04
                    of CA / CT / GA / IL / NV / NJ / RI / VA / WA
                                                                                                                    New York Election of Partners or Self-Employed Persons for
50 NJ     2005/05   Temporary State of New Jersey Insurance Identification Card                 172 NY    7/96
                                                                                                                    Workers’ Compensation Coverage
50 WM     2007/03   Automobile Insurance ID Card (with Watermark)                                                   New York Election of Executive Officers of an Organization for
                                                                                                173 NY    7/96
                                                                                                                    Workers’ Compensation Coverage
51 NJ     2007/06   Permanent State of New Jersey Insurance Identification Card
                                                                                                                    New York Revocation of Executive Officers of an Organization for
60 NJ     2001/10   New Jersey Homeowners Insurance Supplement Flood Exclusion                  174 NY    7/96
                                                                                                                    Workers’ Compensation Coverage
61 NJ     2009/09   New Jersey Auto Insurance Buyer's Guide                                     177 NY    2006/04   NYPIUA Application for Commercial Insurance
62 NJ     2006/10   New Jersey Auto Supplement - Basic Policy Coverage                                                              North Carolina
64 NJ     2006/10   New Jersey Auto Supplement - Standard Policy Coverage                       62 NC     9/97      North Carolina JUA/IUA FAIR and Beach Plan Coverage Instruc.
65 NJ     2003/02   New Jersey Property Insurance Supplement - Earthquake                       64 NC     2008/04   North Carolina Property Supplement - Prop Ins Notice Disclosure
67 NJ     2008/07   NJUIA Dwelling Fire Application                                                                 North Carolina Auto Supplement - Notice of Right to Purchase
                                                                                                65 NC     2009/01   Higher Limits of Uninsured Motorist (UM) and Underinsured
68 NJ     2003/07   NJUIA Commercial Fire Application                                                               Motorist (UIM) Coverage
90 NJ     2000/09   New Jersey Personal Automobile Application                                                      North Carolina Insurance Supplement - Consent to Obtain Credit
                                                                                                66 NC     8/97
                                                                                                                    or Consumer Investigative Report
94 NJ     2006/04   Insurance Inspection Report
                                                                                                90 NC     2009/04   North Carolina Personal Automobile Application Section
                    New Jersey Workers Compensation Insurance Plan
132 NJ    2006/07                                                                               135 NC    2009/08   North Carolina Workers Compensation Application
                    Instructions/Rules
133 NJ    2008/09   New Jersey Workers Compensation Insurance Application                       136 NC    2007/10   NCWCIP, Instructions for Completing ACORD 135 NC App
                    New Jersey Workers Compensation Insurance Plan                              137 NC    2007/06   North Carolina Commercial Auto
134 NJ    2007/01
                    Notice of Election - Proprietors and Partners
                                                                                                138 NC    2007/06   North Carolina Garage and Dealers
                    New Jersey Workers Compensation Insurance Plan
135 NJ    2009/09
                    Supplemental Employee Leasing Application                                                                        North Dakota
                    New Jersey Workers Compensation Insurance Plan                                                  North Dakota Personal Insurance Supplement - Notice of
136 NJ    2009/09                                                                               38 ND     2005/08
                    Truckers Supplemental Application                                                               Information Practices
137 NJ    2008/08   New Jersey Commercial Auto                                                  50 ND     2007/08   North Dakota Insurance Identification Card
138 NJ    2009/04   New Jersey Garage and Dealers                                               68 ND     2004/07   North Dakota Supplement to Property Insurance - Fire District
                    New Jersey Workers Compensation Insurance Plan - NJ Workers                 90 ND     2005/08   North Dakota Personal Auto Application
171 NJ    2003/07
                    Compensation and Employers Liability Manual Part 3, Section 14
                                                                                                137 ND    2002/02   North Dakota Commercial Auto
                                                                                                138 ND    2000/07   North Dakota Garage and Dealers




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                   Page 6 of 10
                                                                                    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
                                             Ohio                                                                                        Rhode Island
67 OH      2009/07   Ohio Mine Subsidence Homeowners and Dwelling Supplement                                           Notice of Information Practices (Privacy) for states
                                                                                                   38        2008/04
                                                                                                                       of CA / CT / GA / IL / NV / NJ / RI / VA / WA
68 OH      2009/07   Ohio Offer of Mine Subsidence - Homeowners and Dwelling
                                                                                                   50 RI     2007/09   Rhode Island Insurance Identification Card
90 OH      2003/09   Ohio Personal Auto Application
                                                                                                   61 RI     4/95      Rhode Island Auto Supplement, UM BI Coverage Notice
137 OH     2002/11   Ohio Commercial Auto
                                                                                                   62 RI     2006/01   Rhode Island Prop Suppl - Notice of Flood Coverage Exclusion
138 OH     2002/11   Ohio Garage and Dealers
                                                                                                                       Rhode Island Joint Reinsurance Association
170 OH     2002/09   Ohio FAIR Plan - Instructions for Completion of Insurance Apps                64 RI     2001/05
                                                                                                                       Application for Homeowners Insurance Inspection and Placement
171 OH     2004/03   Ohio FAIR Plan - Basic Property Application                                                       Rhode Island Joint Reinsurance Association
                                                                                                   65 RI     2001/05
                                                                                                                       Instructions for Completing Homeowners Application ACORD 64 RI
172 OH     2002/09   Ohio FAIR Plan - Homeowners Supplement
                                                                                                                       Rhode Island Joint Underwriting Insurance
173 OH     2002/09   Ohio FAIR Plan - Dwelling Fire Supplement                                     66 RI     2007/03   Application for Dwelling Fire and Personal Liability Insurance
                                                                                                                       Inspection and Placement
174 OH     2002/09   Ohio FAIR Plan - Commercial Supplement
                                                                                                                       Rhode Island Joint Underwriting Insurance
175 OH     2002/09   Ohio FAIR Plan - Farm Supplement                                              67 RI     2007/03   Inspection Notice, Credit Reporting Notice and Instructions for
                                                                                                                       Completing Dwelling Fire and Personal Liability Application ACORD
176 OH     2002/09   Ohio FAIR Plan - Rehabilitation Supplement                                                        66 RI
177 OH     2002/09   Ohio FAIR Plan - Bowling Alley Supplement                                     90 RI     2009/01   Rhode Island Personal Automobile Application Section

                                         Oklahoma                                                  137 RI    2003/05   Rhode Island Commercial Auto
50 OK      2009/08   Oklahoma Owners Security Verification Form                                    138 RI    2003/05   Rhode Island Garage and Dealers
51 OK      2009/08   Oklahoma Operators Security Verification Form                                                                      South Carolina
60 OK      2009/11   Oklahoma Auto Supplement - UM Coverage Law                                    50 SC     2007/01   South Carolina Insurance Identification Card
61 OK      3/94      Oklahoma Auto Supplement - Election of Non-Stacked Coverage                   61 SC     2007/08   South Carolina Auto Supplement - Offer of Opt UM/UIM Coverage
                     Oklahoma Property Supplement                                                  62 SC     2/96      South Carolina Commercial Auto Supplement - Affidavit
62 OK      2006/05
                     Notice to Property Owners in Rural Fire Protection Districts
                                                                                                                       South Carolina Personal Property Supplement - Cancellation Rules
63 OK      10/97     Oklahoma Fraud Statement                                                      64 SC     2008/03
                                                                                                                       Disclosure
64 OK      2007/10   Oklahoma Liability Supplement                                                 71 SC     2003/03   AIP of South Carolina - Private Passenger Policy Change Request
90 OK      2003/12   Oklahoma Personal Auto Application                                            90 SC     2007/08   South Carolina Personal Automobile Application
137 OK     2001/11   Oklahoma Commercial Auto                                                      97 SC     2007/01   AIP of South Carolina - Private Passenger Application
138 OK     3/96      Oklahoma Garage and Dealers                                                   129 SC    2007/01   AIP of South Carolina - Vehicle Schedule

                                           Oregon                                                  137 SC    2007/08   South Carolina Commercial Application
38 OR      2003/05   Oregon Notice of Information Practices (Privacy)                              138 SC    2007/08   South Carolina Garage and Dealers
61 OR      2004/10   Oregon Auto Supplement - UM Coverage Selection                                175 SC    2009/04   AIP of South Carolina - Commercial Auto Policy Change Request
90 OR      2009/07   Oregon Personal Auto Application                                              177 SC    2009/04   AIP of South Carolina - Commercial Application
137 OR     2009/08   Oregon Commercial Auto                                                        179 SC    2009/04   AIP of South Carolina - Garage Application
138 OR     2009/08   Oregon Garage and Dealers                                                     181 SC    2003/03   AIP of South Carolina - Company Performance Complaint Form

                                      Pennsylvania                                                 182 SC    2003/03   AIP of South Carolina - Producer Performance Complaint Form
50 PA      2007/09   Pennsylvania Financial Responsibility Card                                    183 SC    2003/03   AIP of South Carolina - Automobile Loss Notice
60 PA      2008/01   Pennsylvania UM Coverage Select/Reject                                        184 SC    2004/06   AIP of South Carolina - Garage Supplemental Form
61 PA      2007/08   Pennsylvania Auto Supplement - First Party Benefits Coverage                  185 SC    2007/11   AIP of South Carolina - UM/UIM for Private Passenger Risks
62 PA      2008/01   Pennsylvania UIM Coverage Select/Reject                                       186 SC    2007/11   AIP of South Carolina - UM/UIM for Commercial Risks
                     Insurance Placement Facility of Pennsylvania                                  187 SC    2003/03   AIP of South Carolina - Name and/or Ownership Change
64 PA      2006/08
                     Basic Property Insurance Application
                                                                                                                       AIP of South Carolina - Endorsement Voiding Auto Insurance
65                                                                                                 188 SC    2003/03
           2006/08   FAIR Plan Supplementary Questionnaire                                                             While Named Person is Operating Car
PA/DE/WV
                                                                                                                       AIP of South Carolina - Electronic Application Submission
90 PA      2009/07   Pennsylvania Personal Auto Application Section                                851 SC    2003/03
                                                                                                                       Interface Retraction Request Form
137 PA     2009/07   Pennsylvania Commercial Auto                                                                                        South Dakota
138 PA     2009/07   Pennsylvania Garage and Dealers                                               50 SD     2007/02   South Dakota Insurance Identification Card
171 PA     2002/02   Pennsylvania Application for Executive Officer Exception                      90 SD     9/98      South Dakota Personal Auto Application
172 PA     2002/02   Pennsylvania Executive Officers Declaration                                   137 SD    2007/04   South Dakota Commercial Auto

                                       Puerto Rico                                                 138 SD    2/97      South Dakota Garage and Dealers
90 PR      2004/04   Puerto Rico Personal Auto Application                                                                                 Tennessee
                                                                                                   50 TN     2007/02   Tennessee Insurance Identification Card
                                                                                                   90 TN     2005/01   Tennessee Personal Auto Application
                                                                                                   133 TN    2005/10   Tennessee WC Ins Plan - Assigned Risk Supplement
                                                                                                   137 TN    2002/01   Tennessee Commercial Auto
                                                                                                   138 TN    2002/01   Tennessee Garage and Dealers




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                    ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                       Page 7 of 10
                                                                                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
                                           Texas                                                                                        Washington
50 TX     2008/11   Texas Liability Insurance Card                                                                   Notice of Information Practices (Privacy) for states
                                                                                                38         2008/04
                                                                                                                     of CA / CT / GA / IL / NV / NJ / RI / VA / WA
60 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto
                                                                                                90 WA      2009/01   Washington Personal Auto Application Section
62 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto (Spanish)
                                                                                                137 WA     2009/01   Washington Commercial Auto
64 TX     2003/04   Texas Windstorm Insurance Association Application
                                                                                                138 WA     2009/01   Washington Garage and Dealers
67 TX     2007/05   Texas Homeowners and Personal Property - Rights
                                                                                                                                       West Virginia
68 TX     2007/05   Texas Homeowners and Personal Property - Rights (Spanish)
                                                                                                                     West Virginia Personal Insurance Supplement
69 TX     2000/08   Texas Special Mobile Home Windstorm/Haill Application                       38 WV      2006/04
                                                                                                                     Notice of Insurance Information Practices
90 TX     2001/03   Texas Personal Automobile Application                                       50 WV      2008/04   West Virginia Certificate of Insurance
137 TX    2007/08   Texas Commercial Auto                                                       60 WV      12/93     West Virginia Auto Supplement - UM/UIM Vehicle Coverage
138 TX    2007/08   Texas Garage and Dealers                                                    61 WV      2000/10   West Virginia Auto Supplement - UM Coverage Offer Split Limits
851 TX    2004/02   TX Personal Lines Supp. - Use of Credit Information Disclosure              62 WV      2000/10   West Virginia Auto Supplement - UM Coverage Offer Single Limits
                    TX Personal Lines Supp. (Spanish Version) - Use of Credit                                        West Virginia Essential Property Insurance Association
852 TX    2004/02                                                                               64 WV      2006/08
                    Information Disclosure                                                                           Basic Property Insurance Application

                                      United States                                             65 WV      2006/05   West Virginia Umbrella Liability Supplement Important Notice
60 US     2006/04   Insurance Supplement - Offer of Terrorism Coverage                          65
                                                                                                           2006/08   FAIR Plan Supplementary Questionnaire
                                                                                                PA/DE/WV
                    Insurance Supplement - Offer of Terrorism Coverage
62 US     2006/04                                                                                                    West Virginia Umbrella Liability Supplement
                    Standard Fire Policy Only                                                   66 WV      2001/08
                                                                                                                     UM/UIM Coverage - Offer of Split Limits
64 US     2006/04   Insurance Supplement - Offer of Terrorism Coverage Work Comp
                                                                                                                     Mine Subsidence Property Insurance Supplement
                                                                                                67         2008/04
                                            Utah                                                                     Illinois, Indiana, Kentucky, West Virginia
61 UT     2001/02   Utah UM/UIM Coverage Selections                                                                  West Virginia Umbrella Liability Supplement
                                                                                                68 WV      2001/08
                                                                                                                     UM/UIM Coverage - Offer of Single Limits
63 UT     9/93      Utah Fraud Statement
                                                                                                90 WV      2006/01   West Virginia Personal Auto Application
66 UT     6/94      Utah Arbitration Provisions
                                                                                                137 WV     2006/05   West Virginia Commercial Auto
                    Utah Auto Supplement
67 UT     10/94                                                                                 138 WV     2006/05   West Virginia Garage and Dealers
                    PIP Coverage, Loss of Income Waiver
90 UT     2001/01   Utah Personal Automobile Application                                                             West Virginia Property Supplement - Notice of Flood Coverage
                                                                                                862 WV     2005/07
                                                                                                                     Exclusion
137 UT    2001/01   Utah Commercial Auto
                                                                                                                                         Wisconsin
138 UT    2001/01   Utah Garage and Dealers
                                                                                                4 WI       2003/04   Wisconsin Employers First Report of Injury or Disease
                                         Vermont
                                                                                                90 WI      2009/10   Wisconsin Personal Auto Application
50 VT     2007/02   Vermont Automobile Insurance Identification Card
                                                                                                                     Wisconsin Automobile Insurance Plan
66 VT     2003/06   Vermont Insurance Supplement - Fair Credit Reporting Act                    97 WI      2003/10
                                                                                                                     Private Passenger Auto Application
90 VT     2003/06   Vermont Personal Auto Application                                           133 WI     2005/09   Wisconsin Workers Compensation Insurance Pool
137 VT    2003/06   Vermont Commercial Auto                                                     134 WI     8/99      Wisconsin Supplementary Non-Election Form
138 VT    2003/06   Vermont Garage and Dealers                                                  135 WI     8/99      Wisconsin Supplementary Election of Coverage Form

                                     Virgin Islands                                             136 WI     7/96      Wisconsin Supplement Limited Other States Coverage Request
90 VI     2001/03   Virgin Islands Personal Auto Application                                    137 WI     2009/10   Wisconsin Commercial Auto

                                          Virginia                                              138 WI     2009/10   Wisconsin Garage and Dealers
                    Notice of Information Practices (Privacy) for states                        177 WI     2003/10   Wisconsin Automobile Insurance Plan Business Auto Application
38        2008/04
                    of CA / CT / GA / IL / NV / NJ / RI / VA / WA
                                                                                                178 WI     2003/10   Wisconsin Automobile Insurance Plan - Truckers Application
60 VA     8/94      Virginia Auto Supplement - Rental Reimbursement Coverage
                                                                                                                                          Wyoming
                    Virginia Property Supplement
62 VA     6/97                                                                                  90 WY      2006/05   Wyoming Personal Automobile Application
                    Ordinance or Law Coverage; Additional Cov Available
64 VA     2005/01   Virginia Property Supplement - Notice of Flood Insurance                    137 WY     2006/05   Wyoming Commercial Auto
67 VA     2000/11   Virginia Property Insurance Association                                     138 WY     2006/05   Wyoming Garage and Dealers
90 VA     2005/01   Virginia Personal Auto Application
137 VA    2007/05   Virginia Commercial Auto
138 VA    2002/12   Virginia Garage and Dealers
171 VA    2003/02   Virginia Rejection of Coverage - Workers' Comp Act
172 VA    2003/02   Virginia Notice Terminating Prior Rejection of Coverage




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 8 of 10
                                                  ACORD Forms Index
                            ACORD Life/Annuity Forms - Available ONLY on the ACORD Web Site
                                                                                COUNTRYWIDE LIFE FORMS
 Number   Edition   Title                                                                        Number    Edition   Title
650       2009/06   Authorization for the Release of Health Information                         762        2005/03   Policy Effective Date Supplement - Date of Policy Delivery
651       2007/07   Electronic Funds Transfer Authorization Form for Long Term Care Insurance   763        2005/03   Policy Effective Date Supplement - Date Policy Issued
652       2007/07   Credit Card Payment Authorization Form for Long Term Care Insurance         764        2004/03   Fair Credit Reporting Act Disclosure
653       2008/04   Policy Delivery Receipt                                                     765        2004/01   Agent's Report
701       2003/09   Life Insurance Application - Part 1                                         766        2007/03   Life Product Comparison Form
702       2004/03   Life Insurance Application - Part 2 Medical History                         767        2004/03   Temporary Insurance Agreement
703       2004/03   Medical Examiner's Report                                                                        Life Insurance Application - Part 2 Medical History Medical
                                                                                                768        2004/03
                                                                                                                     Condition Details / Additional Care Providers
751       2004/11   Authorization to Obtain and Disclose Information
                                                                                                771        2005/10   Laboratory Identification Form
752       2004/01   Illustration Certification and Acknowledgement
                                                                                                781        2008/01   Informal Inquiry Application - Part 2 Medical History
753       2004/07   Notice of Insurance Information Practices (Pre Notice)
                                                                                                782        2008/01   Medical Examiner's Report
                    Life Insurance Application Supplement - Additional Other
754       2003/09                                                                               783        2008/01   HIV Antibody/Antigen Consent and Testing Form
                    Proposed Insured
755       2003/09   Life Insurance Application Supplement - Additional Owners                                        Informal Inquiry Application - Part 2 Medical History Medical
                                                                                                784        2008/01
                                                                                                                     Condition Details / Additional Care Providers
756       2003/09   Life Insurance Application Supplement - Additional Beneficiaries
                                                                                                951        2009/04   1035 Exchange / Rollover / Transfer Form
757       2004/07   HIV Antibody/Antigen Consent and Testing Form
758       2008/08   Life, Annuity and Health Producer Appointment Form
759       2007/03   Important Notice Regarding Replacement - Model Regulation States
760       2007/03   Important Notice Regarding Replacement

761       2005/03   Policy Effective Date Supplement - Date of Policy Application

                                                                                        STATE LIFE FORMS
 Number   Edition   Title                                                                        Number    Edition   Title
                                          Arizona                                                                                           Maine
751 AZ    2004/12   Arizona Authorization to Obtain and Disclose Information                    701 ME     2003/09   Maine Life Insurance Application - Part 1
757 AZ    2004/12   Arizona HIV Antibody/Antigen Consent and Testing Form                       702 ME     2004/10   Maine Life Insurance Application - Part 2 Medical History

                                       Arkansas                                                 703 ME     2004/03   Maine Medical Examiner's Report
966 AR    2007/03   Arkansas Annuity Product Comparison Form                                    751 ME     2005/02   Maine Authorization to Obtain and Disclose Information

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

757 DC    2004/07
                    District of Columbia HIV Antibody/Antigen Consent and Testing                                                         Maryland
                    Form
                                                                                                701 MD     2005/06   Maryland Life Insurance Application - Part 1
                                          Florida
                                                                                                702 MD     2004/09   Maryland Life Insurance Application - Part 2 Medical History
701 FL    2003/09   Florida Life Insurance Application - Part 1
                                                                                                703 MD     2004/09   Maryland Medical Examiner's Report
                    Florida Life Insurance Application Supplement - Additional Other
754 FL    2003/09                                                                               751 MD     2005/06   Maryland Authorization to Obtain and Disclose Information
                    Proposed Insured
755 FL    2003/09   Florida Life Insurance Application Supplement - Additional Owners                                Maryland Life Insurance Application Supplement - Additional
                                                                                                754 MD     2005/06
                                                                                                                     Other Proposed Insured
756 FL    2003/09   Florida Life Insurance Application Supplement - Additional Beneficiaries
                                                                                                                     Maryland Life Insurance Application Supplement - Additional
757 FL    2005/03   Florida HIV Antibody/Antigen Consent and Testing Form                       755 MD     2004/09
                                                                                                                     Owners
759 FL    2005/06   Florida Notice to Applicant Regarding Replacement of Life Insurance                              Maryland Life Insurance Application Supplement - Additional
                                                                                                756 MD     2004/09
                                                                                                                     Beneficiaries
966 FL    2007/03   Florida Annuity Product Comparison Form
                                                                                                759 MD     2005/06   Maryland Important Notice Regarding Replacement
                    Florida Annuity Product Comparison Form Supplement - Policy / Rider
969 FL    2007/03                                                                                                    Maryland Policy Effective Date Supplement - Date of Policy
                    Description                                                                 761 MD     2005/04
                                                                                                                     Application
                                          Georgia
                                                                                                                     Maryland Policy Effective Date Supplement - Date of Policy
757 GA    2004/12   Georgia HIV Antibody/Antigen Consent and Testing Form                       762 MD     2005/04
                                                                                                                     Delivery

                                           Hawaii                                               763 MD     2005/04   Maryland Policy Effective Date Supplement - Date Policy Issued
759 HI    2007/03   Hawaii Important Notice Regarding Replacement                               767 MD     2004/12   Maryland Temporary Insurance Agreement

                                           Idaho                                                768 MD     2005/06
                                                                                                                     Maryland Life Insurance Application - Part 2 Medical History
                                                                                                                     Medical Condition Details / Additional Care Providers
760 ID    2007/03   Idaho Important Notice Regarding Replacement

                                          Indiana
751 IN    2004/12   Indiana Authorization to Obtain and Disclose Information

                                         Kentucky
767 KY    2004/12   Kentucky Temporary Insurance Agreement




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 9 of 10
                                                  ACORD Forms Index
                            ACORD Life/Annuity 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                                                                                 702 PA    2004/10   Pennsylvania Life Insurance Application - Part 2 Med History
                    Additional Owners
                    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                                                                                 655 VA    2009/06   Virginia Small Employer Group Health Insurance - Medical History Form
                    Insured
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                                                                                 767VA     2004/12   Virginia Temporary Insurance Agreement
                    Insured
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    2005/03   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. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                    Page 10 of 10

								
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