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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               2011/01   Property Loss Notice                                                      74         2009/09   Residence Based Business - Supplement to Residential Section
2               2011/01   Automobile Loss Notice                                                    75         2010/04   Insurance Binder
3               2011/01   General Liability Notice of Occur/Claim                                   76         9/93      Binder Log
4               2011/01   Workers Compensation - First Report of Injury or Illness                  80         2010/05   Homeowner Application
5               2011/01   Aircraft Loss Notice                                                      81         2009/08   Personal Inland Marine Section
6               2009/05   Aviation Witness / Passenger Schedule                                     82         2009/09   Watercraft Section
7               2009/05   Aviation Injured Schedule                                                 83         2011/01   Personal Umbrella Application
11              2/95      Auto Accident Information Form                                            88         2010/05   Personal Insurance Application - Applicant Information Section
12              2/95      Exchange of Information Form                                              89         2010/05   Residential Section
13              2/95      Witness Card                                                              91         2009/10   Good Student Driver Training
20              2009/12   Certificate of Aviation Liability Insurance                               92         2009/10   Medical Statement
21              2009/12   Certificate of Aircraft Insurance                                         93         2009/10   Young Driver Questionnaire
22              2010/03   Intermodal Interchange Certificate of Insurance                           99         2009/02   Accidents / Convictions Schedule
23              2010/05   Vehicle or Equipment Certificate of Insurance                             101        2008/01   Additional Remarks Schedule
24              2009/09   Certificate of Property Insurance                                                              Personal Auto Application Schedule - Additional Resident and
                                                                                                    103        2008/01
                                                                                                                         Driver Information Section
25              2010/05   Certificate of Liability Insurance
                                                                                                    105        2010/12   Apartment Building Supplement
26              2002/01   Policy Certification Log
                                                                                                    106        2010/04   Vacant Building Supplement
27              2009/12   Evidence of Property Insurance
                                                                                                    125        2009/08   Commercial Insurance Application - Applicant Information Section
28              2009/12   Evidence of Commercial Property Insurance
                                                                                                    126        2010/05   Commercial General Liability Section
29              2010/12   Evidence of Flood Insurance
                                                                                                    127        2010/05   Business Auto Section
30              2010/12   Certificate of Garage Insurance
                                                                                                    128        2008/05   Garage and Dealers Section
35              2010/07   Cancellation Request / Policy Release
                                                                                                    129        2009/11   Vehicle Schedule
36              2007/01   Agent/Broker of Record Change
                                                                                                    130        2010/05   Workers Compensation Application
37              2008/01   Statement of No Loss
                                                                                                    131        2009/10   Umbrella Section
42              2009/07   Residential Property Replacement Cost
                                                                                                    132        2008/09   Truckers / Motor Carriers Section
45              2009/04   Additional Interest Schedule
                                                                                                    133        2007/11   Workers Compensation Insurance Plan - Assigned Risk Section
50              2007/02   Automobile Insurance ID Card
                                                                                                    139        2004/03   Statement/Schedule of Values
50 WM           2007/03   Automobile Insurance ID Card (with Watermark)
                                                                                                    140        2010/12   Property Section
54              1/97      Financial Responsibility Form
                                                                                                    141        2009/12   Crime Section 2000
57              1/97      Financial Responsibility Form - Cancellation
                                                                                                    143        2004/01   Transportation Section
58              2007/11   Notice of Cancellation or Termination of Policy
                                                                                                    144        2007/07   Glass And Sign Supplement
60              2010/04   Flood Insurance Selection / Rejection
                                                                                                    145        2004/03   Accounts Receivable/Valuable Papers
60 US           2008/02   Insurance Supplement - Notice - Offer of Terrorism Coverage
                                                                                                    146        2007/02   Equipment Floater Section
                          Insurance Supplement - Standard Fire Policy Only
62 US           2008/02                                                                             147        2001/02   Installation/Builder's Risk Section
                          Notice - Offer of Terrorism Coverage
63              2010/07   Fraud Statements                                                          148        2000/02   Electronic Data Processing Section
                          Insurance Supplement - Workers' Compensation Only                         149        2007/10   Dealers Section
64 US           2008/02
                          Notice - Offer of Terrorism Coverage
                                                                                                    155 BM     2004/12   Boiler & Machinery Section 2002
                          Personal Insurance Supplement - Extraordinary Life
66              2011/05                                                                             159        2004/03   Schedule of Insurance
                          Circumstances
70              2010/05   Personal Policy Change Request (Except Auto)                              160        2009/05   Business Owners Application
71              2009/06   Personal Auto Policy Change Request                                       163        2000/11   Commercial Auto Driver Information Schedule
72              2009/10   Certification of Mobile Home Tie-downs Supplement                         175        2011/03   Commercial Policy Change Request

73              2009/07   Solid Fuel Questionnaire - Supplement to Residential Section              180        1/97      Errors and Omissions Section - Electronic Data Processors, etc.


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                       ACORD Forms Index (rev. 05-31-2011)
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
185       2007/05   Restaurant/Tavern Supplement                                                 410       2004/04   Small Farm/Ranch Application
186       2009/03   Contractors Supplement                                                       501       2004/07   Surety Report of Execution
187       2003/07   Professional Liability Supplement                                            610       2009/04   Premium Payment Supplement
188       2010/06   Employment Related Practices Liability Section                               801       2002/01   Railroad Protective Liability Supplement
190       2009/12   Supplemental Property Application                                            802       2007/07   Hotel/Motel Supplement
193       2001/02   Open Cargo Section                                                           807       2009/12   Directors & Officers Liability Section
194       2009/03   Truckers / Motor Carrier Supplement                                          808       2010/08   P&C Agency Appointment Form
195       10/96     Design Professional's Individual Property Survey                                                 Business Income / Extra Expense / Rental Value
                                                                                                 810       2007/07
                                                                                                                     Supplement to Property Section
196       2010/06   Medical Professional Liability Insurance Application
                                                                                                 811       2007/07   Value Reporting Information Supplement to Property Section
199       1/99      Application Supplement - Undertaking
                                                                                                 812       2006/02   Agency Questionnaire
200       3/93      Producer Account
                                                                                                 813       2005/03   Request for Proof of Property Insurance
201       3/93      Producer Account Discrepancy Notice
                                                                                                 815       2009/02   International Liability Exposure Supplement
210       2001/05   Yacht Section
                                                                                                 816       2005/06   International Property Exposure Supplement
225       1/98      Policyholder's Report
                                                                                                 817       2010/08   P&C Producer Appointment Form - Appointment Section
226       3/93      Statement of Premium Adjustment
                                                                                                 818       2007/08   P&C Producer Appointment Form - Background Questions
275       2009/05   Aviation Insurance Binder
                                                                                                                     P&C Producer Appointment Form - Additional Appointment or
276       2009/05   Aircraft Insurance Binder                                                    819       2010/08
                                                                                                                     Termination
283       2011/01   Personal Umbrella Application Section                                        822       2009/07   Driver Work / School Address Information Supplement
301       2010/10   National Flood Insurance Program - Flood Insurance Application               823       2009/09   Additional Premises Information Schedule
302       2010/10   NFIP - Flood Insurance General Change Endorsement                                                Professional / Specialty Insurance Application - For Use in
                                                                                                 825       2010/12
                                                                                                                     Management, Executive & Professional Lines - Applicant Section
303       2010/10   NFIP - Flood Insurance Preferred Risk Policy Application
                                                                                                 827       2008/01   Employment Practices Liability Insurance Section
304       2010/10   NFIP - Flood Insurance Cancellation / Nullification
                                                                                                 828       2008/07   Fiduciary Liability Coverage Section
305       2011/04   NFIP - Credit Card Payment Form
                                                                                                 829       2009/05   Forms and Endorsements Schedule
306       2011/04   NFIP - Rating Information and Elevated Building Determination
                    Form                                                                         830       2008/11   Property Insurance Card
307       2011/04   NFIP - Floodproofing Certificate for Non-Residential Structures              831       2010/12   Professional / Specialty Insurance Notice of Incident / Claim
308       2011/04   NFIP - Residential Basement Floodproofing Certificate                        832       2011/01   Miscellaneous E&O Section
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              Watermark Paper - 20 # ID Card Stock (4-part perforation)
360 WM              Watermark Paper - 32 # ID Card Stock (4-part perforation)
370 WM              Watermark Paper - 32 # ID Card Stock (non-perforated)
401       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       2009/12   Livestock Mortality Section
408       2007/09   Equine Liability Supplement

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                   ACORD Forms Index (rev. 05-31-2011)
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                                                                                   California (continued)
50 AL     2007/10   Alabama Insurance Identification Card                                           861 CA     2011/07   California Residential Property Insurance Bill of Rights
62 AL     5/98      Alabama Insurance Application Supplement                                                                                  Colorado
90 AL     2010/11   Alabama Personal Auto Application                                               50 CO      2007/03   Colorado Insurance Identification Card
137 AL    2010/11   Alabama Commercial Auto                                                         61 CO      2009/02   Colorado Auto Supplement - Summary of Coverages
138 AL    2010/11   Alabama Garage and Dealers                                                      62 CO      2/97      Colorado Personal Property Supplement - Coverage Disclosure
290 AL    2010/11   Alabama Personal Automobile Application Section                                                      Colorado Auto Supplement - Colorado Offer of Medical Payments
                                                                                                    64 CO      2009/01
                                                                                                                         Coverage
                                           Alaska
                                                                                                    90 CO      2010/08   Colorado Personal Automobile Application
61 AK     7/97      Alaska Auto Supplement - UM/UIM Coverage Selection
                                                                                                    137 CO     2008/01   Colorado Commercial Auto
62 AK     2/98      Alaska Auto Supplement - Exclusion of Named Drivers
                                                                                                    138 CO     2008/01   Colorado Garage and Dealers
90 AK     2005/08   Alaska Personal Auto Application
                                                                                                    171 CO     2006/01   Colorado Rejection of Coverage by Corporate Officers
137 AK    2005/08   Alaska Commercial Auto
                                                                                                    290 CO     2010/08   Colorado Personal Automobile Application Section
138 AK    2005/08   Alaska Garage and Dealers
                                                                                                                                            Connecticut
171 AK    6/98      Alaska Petition For Executive Officer Waiver
                                                                                                                         Notice of Information Practices (Privacy) for states
                                                                                                    38         2011/05
                                         Arkansas                                                                        of CA / CT / GA / IL / NV / NJ / RI / WA
50 AR     2007/10   Arkansas Proof of Insurance Card                                                50 CT      2009/01   Connecticut Insurance Identification Card
61 AR     2010/04   Arkansas Auto Supplement UM/UIM Coverage                                        61 CT      2010/01   Connecticut Auto Supplement - UM Coverage
                    Arkansas Property Supplement - Declination of                                                        Connecticut Personal Insurance Supplement - Summary of
67 AR     2000/02                                                                                   62 CT      2011/07
                    Residential Earthquake Coverage                                                                      Consumer Protections
90 AR     2010/06   Arkansas Personal Auto Application                                              66 CT      2006/06   Connecticut FAIR Plan Application for Property/Liability Insurance
137 AR    2010/08   Arkansas Commercial Auto                                                        90 CT      2011/01   Connecticut Personal Auto Application
138 AR    2010/08   Arkansas Garage and Dealers                                                     137 CT     2011/01   Connecticut Commercial Auto
290 AR    2010/06   Arkansas Personal Auto Application Section                                      138 CT     2011/01   Connecticut Garage and Dealers

                                          Arizona                                                   171 CT     2006/08   Connecticut Workers' Comp. Comm. - Coverage Election by
                                                                                                                         Employee Who Is an Officer of a Corporation, Manager of an
38 AZ     2003/10   Arizona Notice of Information Practices (Privacy)                                                    LLC, or Member of a Multiple-Member LLC
50 AZ     2010/03   Arizona Insurance Identification Card                                           172 CT     2006/08   Connecticut Workers' Comp. Comm. - Coverage Election by
                                                                                                                         Employees who are Members of a Partnership
61 AZ     2001/02   Arizona Auto Supplement UM/UIM Coverage Selection
                                                                                                                         Connecticut Workers' Comp. Comm. - Coverage Election by Sole
90 AZ     2010/11   Arizona Personal Auto Application                                               173 CT     2006/08
                                                                                                                         Proprietor or Single-Member LLC
137 AZ    2010/11   Arizona Commercial Auto                                                         290 CT     2011/01   Connecticut Personal Automobile Application Section
138 AZ    2010/11   Arizona Garage and Dealers                                                                                                Delaware
290 AZ    2010/11   Arizona Personal Automobile Application Section                                                      Delaware Personal Insurance Supplement
                                                                                                    38 DE      2008/04
                                                                                                                         Notice of Information Practices (Privacy)
                                        California
                                                                                                    50 WM      2007/03   Automobile Insurance ID Card (with Watermark)
                    Notice of Information Practices (Privacy) for states
38        2011/05                                                                                                        DE Auto Supplement, DE Motorist's Protection Act - Required
                    of CA / CT / GA / IL / NV / NJ / RI / WA                                        61 DE      2006/10
                                                                                                                         Statement to Policyholders
50 CA     2004/07   California Insurance Identification Card
                                                                                                    62 DE      2004/10   DE Auto Supplement, PIP Deductible Options
51 CA     2004/07   California Evidence of Liability Insurance
                                                                                                                         Insurance Placement Facility of Delaware
52 CA     2007/07   California Fleet Auto Insurance Identification Card                             64 DE      2010/05
                                                                                                                         Basic Property Insurance Application
                    California Auto Supplement - Mandatory UM Bodily Injury /                       65
61 CA     2008/03                                                                                              2006/08   FAIR Plan Supplementary Questionnaire
                    Property Damage Coverage Offer                                                  PA/DE/WV
64 CA     2004/02   California Insurance Supplement - Agency Language                               90 DE      2010/06   Delaware Personal Auto Application
65 CA     2004/07   California Insurance Supplement - Race, National Origin, Gender                 137 DE     2010/08   Delaware Commercial Auto
66 CA     2011/04   California Offer of Earthquake Coverage                                         138 DE     2010/08   Delaware Garage and Dealers
67 CA     2011/07   California Residential Property Insurance Disclosure                            171 DE     2006/01   Delaware Executive Officer(s) Exclusion
                    California Scheduled Personal Property Loss Computation                         290 DE     2010/06   Delaware Personal Auto Application Section
68 CA     2001/03
                    Disclosure
                                                                                                                                      District of Columbia
90 CA     2010/12   California Personal Auto Application
                                                                                                                         Application to District of Columbia Property Insurance Facility for
137 CA    2010/12   California Commercial Auto                                                      64 DC      2010/11
                                                                                                                         Basic Property Insurance
138 CA    2010/12   California Garage and Dealers                                                                        District of Columbia Property Insurance Facility - Essential
                                                                                                    66 DC      2010/10
                                                                                                                         Homeowners Insurance Inspection and Placement Application p. 1
177 CA    2001/03   California Auto Body Repair Consumer Bill of Rights
                                                                                                                         District of Columbia Property Insurance Facility - Essential
290 CA    2010/12   California Personal Auto Application Section                                    67 DC      2010/10
                                                                                                                         Homeowners Insurance Inspection and Placement Application p. 2
                    California FAIR Plan Property Insurance - Application for Dwelling              90 DC      2011/01   District of Columbia Personal Auto Application
854 CA    2011/04
                    Insurance
                                                                                                    137 DC     2011/01   District of Columbia Commercial Auto
                    California FAIR Plan Property Insurance - Application for
855 CA    2011/02                                                                                   138 DC     2011/01   District of Columbia Garage and Dealers
                    Commercial Insurance
                    California FAIR Plan Property Insurance - Application for                       290 DC     2011/01   District of Columbia Personal Auto Application Section
856 CA    2011/02
                    Businessowners (BOP) Insurance
                    California Earthquake Authority - Application for Earthquake
857 CA    2011/02
                    Insurance
860 CA    2004/12   California Auto Supplement - Driver Self Certification

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                      ACORD Forms Index (rev. 05-31-2011)
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                                                                     Notice of Information Practices (Privacy) for states
                                                                                                  38        2011/05
                                                                                                                      of CA / CT / GA / IL / NV / NJ / RI / 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        2011/07
                                                                                                                      Illinois, Indiana, Kentucky, West Virginia
                    Florida Insurance Supplement                                                  69 IL     2010/09   Illinois FAIR Plan - App for Homeowners & Dwelling Property
66 FL     2001/08
                    Credit Report Disclosure Information
                                                                                                  90 IL     2011/03   Illinois Personal Auto Application
67 FL     7/94      Florida Homeowners Supplement
                                                                                                  137 IL    2011/03   Illinois Commercial Auto
                    Citizens Property Insurance Corporation
68 FL     2004/09                                                                                 138 IL    2011/03   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
                                                                                                  290 IL    2011/03   Illinois Personal Auto Application Section
90 FL     2008/05   Florida Personal Auto Application
                                                                                                                                             Indiana
130 FL    2002/07   Florida Workers Compensation Application
                                                                                                  50 IN     2007/11   Indiana Insurance Identification Card
133 FL    2011/01   Florida Workers Comp. Addendum to ACORD 130 FL
                                                                                                                      Mine Subsidence Property Insurance Supplement
                    Florida Workers Comp. Instructions for                                        67        2011/07
134 FL    2010/01                                                                                                     Illinois, Indiana, Kentucky, West Virginia
                    Completing ACORD 130 FL and 133 FL
                                                                                                  90 IN     2010/08   Indiana Personal Auto Application
137 FL    2009/08   Florida Commercial Auto
                                                                                                  137 IN    2010/07   Indiana Commercial Auto
138 FL    2009/08   Florida Garage and Dealers
                                                                                                  138 IN    2010/07   Indiana Garage and Dealers
171 FL    2004/04   Florida Notice of Election of Coverage
                                                                                                  290 IN    2010/08   Indiana Personal Auto Application Section
172 FL    2007/08   Florida Revocation of Election to be Exempt
                                                                                                                                               Iowa
173 FL    2007/08   Florida Notice of Election to be Exempt
                                                                                                  50 IA     2007/08   Iowa Financial Responsibility Card
174 FL    2007/08   Florida Revocation of Election of Coverage
                                                                                                  61 IA     2002/02   Iowa Auto Supplement - UM/UIM Offer/Rejection
175 FL    3/97      Florida Workers Compensation Monthly Change Sheet
                                                                                                  62 IA     2/98      Iowa Auto Supplement - Notice Regarding UM/UIM Coverage
                    Citizens Property Insurance Corporation
220 FL    2003/08                                                                                 64 IA     2/98      Iowa Auto Supplement - UM/UIM Stacking Coverage Notice
                    Commercial and Commercial - Residential Wind Only
                    Citizens Property Ins Corp, Wind Only - Supplemental Application              65 IA     2008/01   Iowa Auto Supplement - Aftermarket Crash Parts
221 FL    2002/07
                    Schedule Commercial and Commercial - Residential
                                                                                                                      Iowa Personal Insurance Supplement
                                                                                                  66 IA     2006/07
                                          Georgia                                                                     Disclosure Use of Claims History
                    Notice of Information Practices (Privacy) for states                                              Iowa Personal Insurance Supplement
38        2011/05                                                                                 67 IA     2010/07
                    of CA / CT / GA / IL / NV / NJ / RI / WA                                                          Extraordinary Life Circumstances Disclosure
50 GA     2008/11   Georgia Insurance Policy Information Card                                     90 IA     2011/01   Iowa Personal Auto Application
51 GA     2005/01   Georgia Fleet Policy Information Card                                         137 IA    2011/02   Iowa Commercial Auto
                    Georgia Auto Supplement - Georgia Auto Disclosure Form,                       138 IA    2011/02   Iowa Garage and Dealers
64 GA     2009/01
                    Notice to Policyholders, Uninsured Motorist Coverage Selection
                                                                                                  290 IA    2011/01   Iowa Personal Automobile Application Section
90 GA     2010/08   Georgia Personal Auto Application
                                                                                                                                             Kansas
137 GA    2009/02   Georgia Commercial Auto
                                                                                                                      Kansas Personal Insurance Supplement - Notice of Insurance
138 GA    2006/11   Georgia Garage and Dealers                                                    38 KS     2011/05
                                                                                                                      Information Practices
171 GA    2001/03   Georgia Workers' Comp - Corporate Officer Rejection                           90 KS     2011/02   Kansas Personal Auto Application
290 GA    2010/08   Georgia Personal Automobile Application Section                               137 KS    2011/03   Kansas Commercial Auto

                                           Hawaii                                                 138 KS    2011/03   Kansas Garage and Dealers
50 HI     2008/01   Hawaii Auto ID Card                                                           171 KS    2005/11   Kansas Elec. of Individual, Partner or Self-Employed Individual
60 HI     2010/07   Hawaii Auto Supplement - UM/UIM/PIP                                           172 KS    2005/11   Kansas Cancel. of Elec. of Individual, Partner or Self-Employed Ind.

90 HI     2005/01   Hawaii Personal Auto Application                                              173 KS    2005/11   Kansas Cancellation of Election Not to Accept Coverage
94 HI     2001/03   Hawaii Vehicle Inspection Report Supplement                                   174 KS    2005/11   Kansas Election Not to Accept Coverage
137 HI    2005/01   Hawaii Commercial Auto                                                        176 KS    2005/11   Kansas Election of Employer to Cover Employees
138 HI    2005/01   Hawaii Garage and Dealers                                                     177 KS    2005/11   Kansas Election of Coverage for Volunteer Workers

                                            Idaho                                                 178 KS    2005/11   Kansas Cancellation of Election of Employer to Cover Employees
50 ID     2007/10   State of Idaho Liability Insurance Identification Card                        179 KS    2005/11   Kansas Cancel. of Election of Coverage for Volunteer Workers
                    Idaho Auto Supplement - Idaho Uninsured Motorist and                          180 KS    2005/11   Kansas Election of Coverage for Persons Performing Public Service
61 ID     2009/01
                    Underinsured Motorist Disclosure Statement
                                                                                                                      Kansas Cancellation of Election of Coverage for Persons
90 ID     2010/08   Idaho Personal Auto Application                                               181 KS    2005/11
                                                                                                                      Performing Public Service
137 ID    2009/01   Idaho Commercial Auto                                                         182 KS    2001/05   Kansas Election of a Noncompensated Volunteer to be Covered
138 ID    2009/01   Idaho Garage and Dealers                                                                          Kansas Cancellation of Election of a Noncompensated Volunteer
                                                                                                  183 KS    2001/05
                                                                                                                      to be Covered
290 ID    2010/08   Idaho Personal Automobile Application Section
                                                                                                  290 KS    2011/02   Kansas Personal Auto Application Section




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                    ACORD Forms Index (rev. 05-31-2011)
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                                                       Massachusetts Residential Property Liability Supplement
                                                                                                  64 MA     2/97
                                                                                                                      Lead Poisoning Liability Disclosure Notice
64 KY     2011/01   Kentucky FAIR Plan Homeowners Application
                                                                                                                      Massachusetts Property Insurance Underwriting Association -
65 KY     2011/01   Kentucky FAIR Plan Dwelling Fire Application                                  65 MA     2010/03
                                                                                                                      Application for Dwelling Fire Insurance Inspection and Placement
66 KY     2011/01   Kentucky FAIR Plan Farm Fire Application                                                          Massachusetts Property Ins Underwriting Assn - Instructions for
                                                                                                  66 MA     2005/01
                                                                                                                      Completing Dwelling Fire Application ACORD 65 MA
                    Mine Subsidence Property Insurance Supplement
67        2011/07                                                                                                     Massachusetts Property Ins Underwriting Assn - Application for
                    Illinois, Indiana, Kentucky, West Virginia                                    67 MA     2003/04
                                                                                                                      Commercial Fire Insurance Inspection and Placement
68 KY     2011/01   Kentucky FAIR Plan Commercial Fire Application
                                                                                                                      Massachusetts Property Insurance Underwriting Association
90 KY     2011/03   Kentucky Personal Auto Application                                            68 MA     2003/04   Inspection Notice, Credit Reporting Notice and Instructions for
                                                                                                                      Completing Commercial Fire Application ACORD 67 MA
137 KY    2011/03   Kentucky Commercial Auto
                                                                                                  69 MA     2010/07   Massachusetts Residential Property Liquid Fuel Spill Supplement
138 KY    2011/03   Kentucky Garage and Dealers
                                                                                                  90 MA     2008/03   Application for Massachusetts Motor Vehicle Insurance
290 KY    2011/03   Kentucky Personal Auto Application Section
                                                                                                  95 MA     2009/12   Massachusetts Renewal Application (Statement of Facts)
                                        Louisiana
                                                                                                  137 MA    2006/05   Massachusetts Commercial Auto
50 LA     2008/03   Louisiana Auto ID Card
                                                                                                  138 MA    2006/05   Massachusetts Garage and Dealers
60 LA     4/98      Louisiana Dwelling Supplement - Loss Settlement DWG1
                                                                                                                                          Michigan
61 LA     2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO4)
                                                                                                  50 MI     2010/08   State of Michigan Certificate of No-Fault Insurance
62 LA     4/98      Louisiana Commercial Property Supplement
                                                                                                                      Michigan Automobile Insurance Placement Facility
64 LA     2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO2 & 3)                   60 MI     2010/03
                                                                                                                      Michigan Auto Supplement - Declaration of Intent to Reside
65 LA     2001/02   Louisiana Homeowners Supplement - Loss Settlement (HO6)                       62 MI     2010/03   Michigan Collision Insurance Options Notice
66 LA     4/98      Louisiana Dwelling Supplement - Loss Settlement DWG2 & 3                      64 MI     2000/10   Michigan Basic Property Insurance Assn Insurance Application
67 LA     5/98      Louisiana Certification of Mobile Home Tie Downs                              90 MI     2010/10   Michigan Personal Auto Application
68 LA     4/98      Louisiana Plan Services Application for Insurance                             133 MI    2009/02   Michigan Application for Workers' Compensation Insurance
90 LA     2010/06   Louisiana Personal Auto Application                                           137 MI    2000/09   Michigan Commercial Auto
137 LA    2010/06   Louisiana Commercial Auto                                                     138 MI    4/96      Michigan Garage and Dealers
138 LA    2009/01   Louisiana Garage and Dealers                                                                      Michigan Automobile Insurance Placement Facility Supplement to
                                                                                                  139 MI    2004/07   ACORD App. - Application for Commercial, Public Automobiles
290 LA    2010/06   Louisiana Personal Auto Application Section                                                       and Corporately Owned Vehicles
861 LA    2005/07   Louisiana Auto Supplement - Active Military Personnel Affidavit               171 MI    2005/01   Michigan Notice of Election
862 LA    2009/06   Louisiana Property Supplement - Hurricane Loss Mitigation Survey              172 MI    4/96      Michigan App for Exclusion of Partner(s), Spouse, Child or Parent

                                          Maine                                                   173 MI    2000/09   Michigan WC Placement Facility Specific Person Exclusion
50 ME     2007/08   Maine Motor Vehicle Insurance Identification Card                             290 MI    2010/10   Michigan Personal Automobile Application Section
90 ME     2011/02   Maine Personal Auto Application                                               860 MI    2010/03   Michigan Auto Supplement - Declaration of Intent to Reside
137 ME    2011/02   Maine Commercial Auto                                                                                                 Minnesota
138 ME    2011/02   Maine Garage and Dealers                                                      38 MN     2011/05   Minnesota Authorization
290 ME    2011/02   Maine Personal Auto Application Section                                       62 MN     2000/01   Minnesota Auto Supplement

                                        Maryland                                                  65 MN     2005/06   Minnesota Guaranty Association Notice
39 MD     2003/05   Maryland Application Supp Notice of Intent to Use Credit History              90 MN     2006/08   Minnesota Personal Auto Application
62 MD     1/98      Maryland Commercial Auto Supplement                                           137 MN    2006/08   Minnesota Commercial Auto
                    Maryland Property Insurance Availability Program                              138 MN    2006/08   Minnesota Garage and Dealers
64 MD     2010/11
                    Essential Property Insurance Inspection and Placement
                                                                                                  853 MN    2010/08   Minnesota Home Owners Personal Property Supplement
                    Maryland Property Insurance Availability Program - Essential
65 MD     2010/10   Homeowners Insurance Inspection and Placement (p. 1 of 2)                                                            Mississippi
                    Maryland Property Insurance Availability Program - Essential                  50 MS     2008/01   Mississippi Auto Insurance ID Card
66 MD     2010/10
                    Homeowners Insurance Inspection and Placement (p. 2 of 2)
                                                                                                  61 MS     2006/01   Mississippi Auto Supplement - Non-Stacking UM Insurance
                    Maryland Personal Auto Supplement - Mandatory Offer of
67 MD     2011/01   Increased Liability Coverage for Claims of Family Members,                    90 MS     2011/02   Mississippi Personal Auto Application
                    Mandatory PIP Waiver, and Mandatory UM Coverage Waiver
                                                                                                  137 MS    2011/02   Mississippi Commercial Auto
                    Maryland Personal Property Supplement - Statement Regarding
68 MD     2007/01                                                                                 138 MS    2011/02   Mississippi Garage and Dealers
                    Flood Insurance
69 MD     2007/01   Maryland Insurance Supplement - Notice of Underwriting Period                 139 MS    2/99      Mississippi Statement/Schedule of Values
90 MD     2010/09   Maryland Personal Auto Application                                            290 MS    2011/02   Mississippi Personal Auto Application Section
137 MD    2009/12   Maryland Commercial Auto                                                                                               Missouri
138 MD    2009/12   Maryland Garage and Dealers                                                   50 MO     2007/05   Missouri Auto Insurance ID Card
290 MD    2010/09   Maryland Personal Automobile Application Section                                                  Missouri Property Supplement - Notice of Availability of
                                                                                                  62 MO     2007/08
                                                                                                                      Earthquake Insurance
                    Maryland Personal Property Supplement - Loss from Water and
851 MD    2008/11                                                                                 67 MO     2009/06   Missouri FAIR Plan Insurance Application
                    Sewer Backup

                                    Massachusetts                                                 90 MO     2010/10   Missouri Personal Auto Application
                    Massachusetts Property Insurance Underwriting Association                     137 MO    2008/08   Missouri Commercial Auto
60 MA     2010/03
                    Application for Homeowners Insurance
                                                                                                  138 MO    2008/08   Missouri Garage and Dealers
                    Massachusetts Property Insurance Underwriting Association
61 MA     2003/04                                                                                 290 MO    2010/10   Missouri Personal Auto Application Section
                    Instructions to Complete Homeowners Application ACORD 60 MA

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                   ACORD Forms Index (rev. 05-31-2011)
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 Jersey (continued)
60 MT     2003/09   Montana Application Supplement - Refusal to Renew                        137 NJ    2008/08   New Jersey Commercial Auto
90 MT     2010/06   Montana Personal Auto Application                                        138 NJ    2009/04   New Jersey Garage and Dealers
                    Montana State Compensation Insurance Fund                                                    New Jersey Workers Compensation Insurance Plan - NJ Workers
133 MT    8/98                                                                               171 NJ    2003/07
                    Worker’s Compensation Application Supplement                                                 Compensation and Employers Liability Manual Part 3, Section 14
137 MT    2009/08   Montana Commercial Auto                                                                                        New Mexico
138 MT    2009/08   Montana Garage and Dealers                                               60 NM     2003/01   New Mexico Confidential Abuse Disclosure
290 MT    2010/06   Montana Personal Auto Application Section                                                    New Mexico Auto Supplement - UM Coverage Selection/Rejection
                                                                                             61 NM     2010/12
                                                                                                                 and Rejection Of Stacked UM Coverage
                                         Nebraska
                                                                                             90 NM     2006/02   New Mexico Personal Auto Application
50 NE     2007/01   Nebraska Auto Liability Insurance Identification Card
                                                                                             137 NM    2005/04   New Mexico Commercial Auto
90 NE     2010/06   Nebraska Personal Auto Application
                                                                                             138 NM    2005/01   New Mexico Garage and Dealers
137 NE    2010/01   Nebraska Commercial Auto
                                                                                             171 NM    2004/10   New Mexico Executive Employee Affirmative Election Form
138 NE    2010/01   Nebraska Garage and Dealers
                                                                                             172 NM    2004/10   New Mexico Election to Accept
290 NE    2010/06   Nebraska Personal Auto Application Section
                                                                                             173 NM    2004/10   New Mexico Revocation
                                          Nevada
                                                                                             174 NM    2004/10   NM Limited Liability Company Member Affirmative Election Form
                    Notice of Information Practices (Privacy) for states
38        2011/05
                    of CA / CT / GA / IL / NV / NJ / RI / WA                                                                         New York
51 NV     2010/05   Nevada Temporary Insurance Identification Card                                               New York Personal Insurance Supplement - Notice of Information
                                                                                             38 NY     2005/04
                                                                                                                 Practices
52 NV     2010/05   Nevada Permanent Insurance Identification Card
                                                                                             39 NY     2011/03   New York Insurance Supplement
                    Nevada Temporary Insurance Identification Card, Evidence of
53 NV     2011/05                                                                            60 NY     2008/03   New York Homeowners Supplement
                    Operator's Policy of Liability Insurance
                    Nevada Permanent Insurance Identification Card, Evidence of              61 NY     3/94      New York Auto Supplement (Optional Basic Econ Loss)
54 NV     2011/05
                    Operator's Policy of Liability Insurance
                                                                                             62 NY     2009/04   New York Application For Dwelling Insurance - NYPIUA
                    Nevada Auto Supplement, Mandatory Offer of Medical Payments
61 NV     2002/12                                                                            64 NY     2008/06   New York Auto Supplement - Supp UM/UIM Insurance Coverage
                    Coverage and Uninsured Motorists Coverage
62 NV     2001/05   Nevada Umbrella Supplement                                               65 NY     2003/01   New York Auto Supplement - Spousal Liability Coverage
90 NV     2011/04   Nevada Personal Auto Application                                         67 NY     2009/04   Instructions for Completion of ACORD 62 NY
137 NV    2011/04   Nevada Commercial Auto                                                   68 NY     2002/01   New York Liability Supplement - "Claims-Made Policy"
138 NV    2011/04   Nevada Garage and Dealers                                                                    New York Personal Property Supplement - Important Flood
                                                                                             69 NY     2008/08
                                                                                                                 Insurance Notice
290 NV    2011/04   Nevada Personal Auto Application Section
                                                                                             70 NY     2006/04   NYPIUA Instructions for Completing ACORD 177 NY
                                    New Hampshire
                                                                                             90 NY     2005/04   New York Personal Auto Application
90 NH     2010/06   New Hampshire Personal Auto Application
                                                                                             137 NY    2003/11   New York Commercial Auto
137 NH    2010/06   New Hampshire Commercial Auto
                                                                                             138 NY    2003/11   New York Garage and Dealers
138 NH    2010/02   New Hampshire Garage and Dealers
                                                                                             171 NY    10/96     New York Notice of Election of a Corporation
290 NH    2010/06   New Hampshire Personal Auto Application Section
                                                                                                                 New York Election of Partners or Self-Employed Persons for
                                                                                             172 NY    7/96
                                      New Jersey                                                                 Workers’ Compensation Coverage
                    Notice of Information Practices (Privacy) for states                                         New York Election of Executive Officers of an Organization for
38        2011/05                                                                            173 NY    7/96
                    of CA / CT / GA / IL / NV / NJ / RI / WA                                                     Workers’ Compensation Coverage
50 NJ     2005/05   Temporary State of New Jersey Insurance Identification Card                                  New York Revocation of Executive Officers of an Organization for
                                                                                             174 NY    7/96
                                                                                                                 Workers’ Compensation Coverage
50 WM     2007/03   Automobile Insurance ID Card (with Watermark)
                                                                                             177 NY    2006/04   NYPIUA Application for Commercial Insurance
51 NJ     2007/06   Permanent State of New Jersey Insurance Identification Card
                                                                                                                                 North Carolina
60 NJ     2001/10   New Jersey Homeowners Insurance Supplement Flood Exclusion
                                                                                             62 NC     9/97      North Carolina JUA/IUA FAIR and Beach Plan Coverage Instruc.
61 NJ     2009/09   New Jersey Auto Insurance Buyer's Guide
                                                                                             64 NC     2008/04   North Carolina Property Supplement - Prop Ins Notice Disclosure
62 NJ     2006/10   New Jersey Auto Supplement - Basic Policy Coverage
                                                                                                                 North Carolina Auto Supplement - Notice of Right to Purchase
64 NJ     2010/03   New Jersey Auto Supplement - Standard Policy Coverage                    65 NC     2010/02   Higher Limits of Uninsured Motorist (UM) and Underinsured
                                                                                                                 Motorist (UIM) Coverage
65 NJ     2003/02   New Jersey Property Insurance Supplement - Earthquake
                                                                                                                 North Carolina Insurance Supplement - Consent to Obtain Credit
67 NJ     2010/08   NJUIA Dwelling Fire Application                                          66 NC     8/97
                                                                                                                 or Consumer Investigative Report
68 NJ     2010/05   NJUIA Commercial Fire Application                                        90 NC     2010/06   North Carolina Personal Auto Application
90 NJ     2000/09   New Jersey Personal Auto Application                                     135 NC    2009/08   North Carolina Workers Compensation Application
94 NJ     2006/04   Insurance Inspection Report                                              136 NC    2007/10   NCWCIP, Instructions for Completing ACORD 135 NC App
                    New Jersey Workers Compensation Insurance Plan                           137 NC    2010/02   North Carolina Commercial Auto
132 NJ    2006/07
                    Instructions/Rules
                                                                                             138 NC    2010/02   North Carolina Garage and Dealers
133 NJ    2008/09   New Jersey Workers Compensation Insurance Application
                                                                                             290 NC    2010/06   North Carolina Personal Automobile Application Section
                    New Jersey Workers Compensation Insurance Plan
134 NJ    2007/01
                    Notice of Election - Proprietors and Partners

                    New Jersey Workers Compensation Insurance Plan
135 NJ    2009/09
                    Supplemental Employee Leasing Application

                    New Jersey Workers Compensation Insurance Plan
136 NJ    2009/09
                    Truckers Supplemental Application


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                             ACORD Forms Index (rev. 05-31-2011)
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
                                      North Dakota                                                                              Pennsylvania (continued)
                     North Dakota Personal Insurance Supplement - Notice of                        172 PA    2002/02   Pennsylvania Executive Officers Declaration
38 ND      2005/08
                     Information Practices
                                                                                                   290 PA    2010/09   Pennsylvania Personal Auto Application Section
50 ND      2007/08   North Dakota Insurance Identification Card
                                                                                                                                          Puerto Rico
68 ND      2004/07   North Dakota Supplement to Property Insurance - Fire District
                                                                                                   90 PR     2004/04   Puerto Rico Personal Auto Application
90 ND      2005/08   North Dakota Personal Auto Application
                                                                                                                                         Rhode Island
137 ND     2002/02   North Dakota Commercial Auto
                                                                                                                       Notice of Information Practices (Privacy) for states
138 ND     2000/07   North Dakota Garage and Dealers                                               38        2011/05
                                                                                                                       of CA / CT / GA / IL / NV / NJ / RI / WA

                                             Ohio                                                  50 RI     2008/01   Rhode Island Insurance Identification Card
                     Ohio Auto Supplement - Important Optional Disclosure Notice                   61 RI     4/95      Rhode Island Auto Supplement, UM BI Coverage Notice
62 OH      2011/05
                     Uninsured Motorist Property Damage Coverage
                                                                                                   62 RI     2006/01   Rhode Island Prop Suppl - Notice of Flood Coverage Exclusion
67 OH      2009/07   Ohio Mine Subsidence Homeowners and Dwelling Supplement
                                                                                                                       Rhode Island Joint Reinsurance Association
68 OH      2009/07   Ohio Offer of Mine Subsidence - Homeowners and Dwelling                       64 RI     2010/03
                                                                                                                       Application for Homeowners Insurance Inspection and Placement
90 OH      2003/09   Ohio Personal Auto Application                                                                    Rhode Island Joint Reinsurance Association
                                                                                                   65 RI     2003/04
                                                                                                                       Instructions for Completing Homeowners Application ACORD 64 RI
137 OH     2002/11   Ohio Commercial Auto
                                                                                                                       Rhode Island Joint Underwriting Insurance
138 OH     2002/11   Ohio Garage and Dealers                                                       66 RI     2010/03   Application for Dwelling Fire and Personal Liability Insurance
                                                                                                                       Inspection and Placement
170 OH     2002/09   Ohio FAIR Plan - Instructions for Completion of Insurance Apps
                                                                                                                       Rhode Island Joint Underwriting Insurance
171 OH     2004/03   Ohio FAIR Plan - Basic Property Application                                   67 RI     2007/03   Inspection Notice, Credit Reporting Notice and Instructions for
                                                                                                                       Completing Dwelling Fire and Personal Liability Application
172 OH     2002/09   Ohio FAIR Plan - Homeowners Supplement                                                            ACORD 66 RI
173 OH     2002/09   Ohio FAIR Plan - Dwelling Fire Supplement                                                         Rhode Island Joint Underwriting Insurance
                                                                                                   68 RI     2003/04   Application for Commercial Fire Insurance Inspection and
174 OH     2002/09   Ohio FAIR Plan - Commercial Supplement                                                            Placement
175 OH     2002/09   Ohio FAIR Plan - Farm Supplement                                                                  Rhode Island Joint Underwriting Insurance
                                                                                                   69 RI     2003/04   Inspection Notice, Credit Reporting Notice and Instructions for
176 OH     2002/09   Ohio FAIR Plan - Rehabilitation Supplement                                                        Completing Commercial Fire Application ACORD 68 RI
177 OH     2002/09   Ohio FAIR Plan - Bowling Alley Supplement                                     90 RI     2010/06   Rhode Island Personal Auto Application

                                         Oklahoma                                                  137 RI    2010/02   Rhode Island Commercial Auto
50 OK      2009/08   Oklahoma Owners Security Verification Form                                    138 RI    2010/02   Rhode Island Garage and Dealers
51 OK      2009/08   Oklahoma Operators Security Verification Form                                 290 RI    2010/06   Rhode Island Personal Automobile Application Section
60 OK      2009/11   Oklahoma Auto Supplement - UM Coverage Law                                                                         South Carolina
61 OK      3/94      Oklahoma Auto Supplement - Election of Non-Stacked Coverage                   50 SC     2007/01   South Carolina Insurance Identification Card
                     Oklahoma Property Supplement                                                  61 SC     2007/08   South Carolina Auto Supplement - Offer of Opt UM/UIM Coverage
62 OK      2006/05
                     Notice to Property Owners in Rural Fire Protection Districts
                                                                                                   62 SC     2/96      South Carolina Commercial Auto Supplement - Affidavit
63 OK      10/97     Oklahoma Fraud Statement
                                                                                                                       South Carolina Personal Property Supplement - Cancellation Rules
64 OK      2007/10   Oklahoma Liability Supplement                                                 64 SC     2008/03
                                                                                                                       Disclosure
90 OK      2011/05   Oklahoma Personal Auto Application                                            71 SC     2010/12   AIP of South Carolina - Private Passenger Policy Change Request
137 OK     2011/05   Oklahoma Commercial Auto                                                      90 SC     2007/08   South Carolina Personal Auto Application
138 OK     2011/05   Oklahoma Garage and Dealers                                                   97 SC     2010/09   AIP of South Carolina - Private Passenger Application
290 OK     2011/05   Oklahoma Personal Auto Application Section                                    129 SC    2010/02   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    2010/12   AIP of South Carolina - Commercial Auto Policy Change Request
62 OR      2006/01   Oregon Personal Lines Supplement                                              177 SC    2010/09   AIP of South Carolina - Commercial Application
90 OR      2009/07   Oregon Personal Auto Application                                              179 SC    2009/04   AIP of South Carolina - Garage Application
137 OR     2009/08   Oregon Commercial Auto                                                        181 SC    2003/03   AIP of South Carolina - Company Performance Complaint Form
138 OR     2009/08   Oregon Garage and Dealers                                                     182 SC    2003/03   AIP of South Carolina - Producer Performance Complaint Form

                                      Pennsylvania                                                 183 SC    2003/03   AIP of South Carolina - Automobile Loss Notice
50 PA      2007/09   Pennsylvania Financial Responsibility Card                                    184 SC    2004/06   AIP of South Carolina - Garage Supplemental Form
60 PA      2008/01   Pennsylvania UM Coverage Select/Reject                                        185 SC    2007/11   AIP of South Carolina - UM/UIM for Private Passenger Risks
61 PA      2007/08   Pennsylvania Auto Supplement - First Party Benefits Coverage                  186 SC    2007/11   AIP of South Carolina - UM/UIM for Commercial Risks
62 PA      2008/01   Pennsylvania UIM Coverage Select/Reject                                       187 SC    2003/03   AIP of South Carolina - Name and/or Ownership Change
                     Insurance Placement Facility of Pennsylvania                                                      AIP of South Carolina - Endorsement Voiding Auto Insurance
64 PA      2010/05                                                                                 188 SC    2003/03
                     Basic Property Insurance Application                                                              While Named Person is Operating Car
65                                                                                                                     AIP of South Carolina - Electronic Application Submission
           2006/08   FAIR Plan Supplementary Questionnaire                                         851 SC    2003/03
PA/DE/WV                                                                                                               Interface Retraction Request Form
90 PA      2010/09   Pennsylvania Personal Auto Application
137 PA     2009/07   Pennsylvania Commercial Auto
138 PA     2009/07   Pennsylvania Garage and Dealers

171 PA     2002/02   Pennsylvania Application for Executive Officer Exception


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                    ACORD Forms Index (rev. 05-31-2011)
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
                                     South Dakota                                                                                 Virginia (continued)
50 SD     2007/02   South Dakota Insurance Identification Card                                  90 VA      2010/04   Virginia Personal Auto Application
90 SD     2011/05   South Dakota Personal Auto Application                                      137 VA     2010/06   Virginia Commercial Auto
137 SD    2011/05   South Dakota Commercial Auto                                                138 VA     2010/06   Virginia Garage and Dealers
138 SD    2011/05   South Dakota Garage and Dealers                                             171 VA     2003/02   Virginia Rejection of Coverage - Workers' Comp Act
290 SD    2011/05   South Dakota Personal Auto Application Section                              172 VA     2003/02   Virginia Notice Terminating Prior Rejection of Coverage

                                       Tennessee                                                290 VA     2010/04   Virginia Personal Auto Application Section
50 TN     2007/02   Tennessee Insurance Identification Card                                                                             Washington
90 TN     2005/01   Tennessee Personal Auto Application                                                              Notice of Information Practices (Privacy) for states
                                                                                                38         2011/05
                                                                                                                     of CA / CT / GA / IL / NV / NJ / RI / WA
133 TN    2005/10   Tennessee WC Ins Plan - Assigned Risk Supplement
                                                                                                90 WA      2010/10   Washington Personal Auto Application
137 TN    2002/01   Tennessee Commercial Auto
                                                                                                137 WA     2009/01   Washington Commercial Auto
138 TN    2002/01   Tennessee Garage and Dealers
                                                                                                138 WA     2009/01   Washington Garage and Dealers
                                           Texas
                                                                                                290 WA     2010/10   Washington Personal Auto Application Section
50 TX     2008/11   Texas Liability Insurance Card
                                                                                                                                       West Virginia
60 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto
                                                                                                                     West Virginia Personal Insurance Supplement
62 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto (Spanish)                   38 WV      2006/04
                                                                                                                     Notice of Insurance Information Practices
64 TX     2003/04   Texas Windstorm Insurance Association Application                           50 WV      2008/04   West Virginia Certificate of Insurance
67 TX     2007/05   Texas Homeowners and Personal Property - Rights                             60 WV      12/93     West Virginia Auto Supplement - UM/UIM Vehicle Coverage
68 TX     2007/05   Texas Homeowners and Personal Property - Rights (Spanish)                   61 WV      2000/10   West Virginia Auto Supplement - UM Coverage Offer Split Limits
69 TX     2000/08   Texas Special Mobile Home Windstorm/Haill Application                       62 WV      2000/10   West Virginia Auto Supplement - UM Coverage Offer Single Limits
90 TX     2001/03   Texas Personal Auto Application                                                                  West Virginia Essential Property Insurance Association
                                                                                                64 WV      2010/05
                                                                                                                     Basic Property Insurance Application
137 TX    2007/08   Texas Commercial Auto
                                                                                                65 WV      2006/05   West Virginia Umbrella Liability Supplement Important Notice
138 TX    2007/08   Texas Garage and Dealers
                                                                                                65
851 TX    2010/06   TX Personal Lines Supp. - Use of Credit Information Disclosure                         2006/08   FAIR Plan Supplementary Questionnaire
                                                                                                PA/DE/WV
                    TX Personal Lines Supp. (Spanish Version) - Use of Credit                                        West Virginia Umbrella Liability Supplement
852 TX    2010/06                                                                               66 WV      2001/08
                    Information Disclosure                                                                           UM/UIM Coverage - Offer of Split Limits

                                     United States                                              67         2011/07
                                                                                                                     Mine Subsidence Property Insurance Supplement
                                                                                                                     Illinois, Indiana, Kentucky, West Virginia
60 US     2008/02   Insurance Supplement - Offer of Terrorism Coverage
                                                                                                                     West Virginia Umbrella Liability Supplement
                    Insurance Supplement - Offer of Terrorism Coverage                          68 WV      2001/08
62 US     2008/02                                                                                                    UM/UIM Coverage - Offer of Single Limits
                    Standard Fire Policy Only
                                                                                                90 WV      2006/01   West Virginia Personal Auto Application
64 US     2008/02   Insurance Supplement - Offer of Terrorism Coverage Work Comp
                                                                                                137 WV     2006/05   West Virginia Commercial Auto
                                            Utah
                                                                                                138 WV     2006/05   West Virginia Garage and Dealers
61 UT     2010/08   Utah UM/UIM Coverage Selections
                                                                                                                     West Virginia Property Supplement - Notice of Flood Coverage
63 UT     9/93      Utah Fraud Statement                                                        862 WV     2005/07
                                                                                                                     Exclusion
66 UT     6/94      Utah Arbitration Provisions                                                                                          Wisconsin
                    Utah Auto Supplement                                                        4 WI       2003/04   Wisconsin Employers First Report of Injury or Disease
67 UT     10/94
                    PIP Coverage, Loss of Income Waiver
                                                                                                90 WI      2010/06   Wisconsin Personal Auto Application
90 UT     2011/05   Utah Personal Auto Application
                                                                                                                     Wisconsin Automobile Insurance Plan
137 UT    2011/05   Utah Commercial Auto                                                        97 WI      2003/10
                                                                                                                     Private Passenger Auto Application
138 UT    2011/05   Utah Garage and Dealers                                                     133 WI     2010/04   Wisconsin Workers Compensation Insurance Pool
290 UT    2011/05   Utah Personal Auto Application Section                                      134 WI     8/99      Wisconsin Supplementary Non-Election Form

                                         Vermont                                                135 WI     8/99      Wisconsin Supplementary Election of Coverage Form
50 VT     2007/02   Vermont Automobile Insurance Identification Card                            136 WI     2010/04   Wisconsin Supplement Limited Other States Coverage Request
66 VT     2003/06   Vermont Insurance Supplement - Fair Credit Reporting Act                    137 WI     2009/10   Wisconsin Commercial Auto
90 VT     2011/05   Vermont Personal Auto Application                                           138 WI     2009/10   Wisconsin Garage and Dealers
137 VT    2011/05   Vermont Commercial Auto                                                     177 WI     2009/11   Wisconsin Automobile Insurance Plan Business Auto Application
138 VT    2011/05   Vermont Garage and Dealers                                                  178 WI     2009/11   Wisconsin Automobile Insurance Plan - Truckers Application
290 VT    2011/05   Vermont Personal Auto Application Section                                   290 WI     2010/06   Wisconsin Personal Auto Application Section

                                     Virgin Islands                                                                                       Wyoming
90 VI     2001/03   Virgin Islands Personal Auto Application                                    90 WY      2006/05   Wyoming Personal Auto Application

                                          Virginia                                              137 WY     2006/05   Wyoming Commercial Auto
38 VA     2011/05   Virginia Notice of Information Practices (Privacy)                          138 WY     2006/05   Wyoming Garage and Dealers
60 VA     8/94      Virginia Auto Supplement - Rental Reimbursement Coverage
                    Virginia Property Supplement
62 VA     6/97
                    Ordinance or Law Coverage; Additional Cov Available
64 VA     2005/01   Virginia Property Supplement - Notice of Flood Insurance
67 VA     2000/11   Virginia Property Insurance Association

ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                   ACORD Forms Index (rev. 05-31-2011)
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/Health 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                         763        2005/03   Policy Effective Date Supplement - Date Policy Issued
651       2007/07   Electronic Funds Transfer Authorization Form for Long Term Care Insurance   764        2004/03   Fair Credit Reporting Act Disclosure
652       2007/07   Credit Card Payment Authorization Form for Long Term Care Insurance         765        2004/01   Agent's Report
653       2008/04   Policy Delivery Receipt                                                     766        2007/03   Life Product Comparison Form
701       2003/09   Life Insurance Application - Part 1                                         767        2004/03   Temporary Insurance Agreement
702       2004/03   Life Insurance Application - Part 2 Medical History                                              Life Insurance Application - Part 2 Medical History Medical
                                                                                                768        2004/03
                                                                                                                     Condition Details / Additional Care Providers
703       2004/03   Medical Examiner's Report
                                                                                                771        2005/10   Laboratory Identification Form
731       2010/05   Request for Proposal - Additional Unions Schedule
                                                                                                781        2008/01   Informal Inquiry Application - Part 2 Medical History
732       2010/05   Request for Proposal - Additional Locations Schedule
                                                                                                782        2008/01   Medical Examiner's Report
733       2010/05   Request for Proposal - Additional Covered Affiliates Schedule
                                                                                                783        2008/01   HIV Antibody/Antigen Consent and Testing Form
751       2004/11   Authorization to Obtain and Disclose Information
                                                                                                                     Informal Inquiry Application - Part 2 Medical History Medical
752       2004/01   Illustration Certification and Acknowledgement                              784        2008/01
                                                                                                                     Condition Details / Additional Care Providers
753       2004/07   Notice of Insurance Information Practices (Pre Notice)                      785        2010/05   Request for Proposal - Employee Benefits
                    Life Insurance Application Supplement - Additional Other                    786        2010/05   Request for Proposal - Life Supplement
754       2003/09
                    Proposed Insured
                                                                                                787        2010/05   Request for Proposal - Short Term Disability Supplement
755       2003/09   Life Insurance Application Supplement - Additional Owners
                                                                                                788        2010/05   Request for Proposal - Long Term Disability Supplement
756       2003/09   Life Insurance Application Supplement - Additional Beneficiaries
                                                                                                789        2010/05   Age Banded Rate Supplement
757       2004/07   HIV Antibody/Antigen Consent and Testing Form
                                                                                                790        2010/05   Reducing Benefit Duration Schedule
758       2011/03   Life, Annuity and Health Producer Appointment Form
                                                                                                791        2010/05   Administrative Services and Fee Schedule - Long Term Disability
759       2007/03   Important Notice Regarding Replacement - Model Regulation States
                                                                                                792        2010/05   Administrative Services and Fee Schedule - Short Term Disability
760       2007/03   Important Notice Regarding Replacement
                                                                                                951        2011/03   1035 Exchange / Rollover / Transfer Form
761       2005/03   Policy Effective Date Supplement - Date of Policy Application
762       2005/03   Policy Effective Date Supplement - Date of Policy Delivery

                                                                                        STATE LIFE FORMS
 Number   Edition   Title                                                                        Number    Edition   Title
                                          Arizona                                                                                        Kentucky
751 AZ    2004/12   Arizona Authorization to Obtain and Disclose Information                    767 KY     2004/12   Kentucky Temporary Insurance Agreement
757 AZ    2004/12   Arizona HIV Antibody/Antigen Consent and Testing Form                                                                   Maine
                                       Arkansas                                                 701 ME     2003/09   Maine Life Insurance Application - Part 1
966 AR    2007/03   Arkansas Annuity Product Comparison Form                                    702 ME     2004/10   Maine Life Insurance Application - Part 2 Medical History

                                        California                                              703 ME     2004/03   Maine Medical Examiner's Report
757 CA    2004/07   California HIV Antibody/Antigen Consent and Testing Form                    751 ME     2005/02   Maine Authorization to Obtain and Disclose Information
760 CA    2007/03   California Notice Regarding Replacement                                                          Maine Life Insurance Application Supplement - Additional Other
                                                                                                754 ME     2003/09
                                                                                                                     Proposed Insured
966 CA    2007/03   California Annuity Product Comparison Form
                                                                                                757 ME     2004/07   Maine HIV Antibody/Antigen Consent and Testing Form
                                 District of Columbia
                                                                                                767 ME     2005/02   Maine Temporary Insurance Agreement
                    District of Columbia HIV Antibody/Antigen Consent and Testing
757 DC    2004/07                                                                                                    Maine Life Insurance Application - Part 2 Medical History
                    Form                                                                        768 ME     2004/10
                                                                                                                     Medical Condition Details / Additional Care Providers
                                          Florida
                                                                                                                                          Maryland
701 FL    2003/09   Florida Life Insurance Application - Part 1
                                                                                                701 MD     2005/06   Maryland Life Insurance Application - Part 1
                    Florida Life Insurance Application Supplement - Additional Other
754 FL    2003/09                                                                               702 MD     2004/09   Maryland Life Insurance Application - Part 2 Medical History
                    Proposed Insured
755 FL    2003/09   Florida Life Insurance Application Supplement - Additional Owners           703 MD     2004/09   Maryland Medical Examiner's Report
756 FL    2003/09   Florida Life Insurance Application Supplement - Additional Beneficiaries    751 MD     2005/06   Maryland Authorization to Obtain and Disclose Information
757 FL    2005/03   Florida HIV Antibody/Antigen Consent and Testing Form                                            Maryland Life Insurance Application Supplement - Additional
                                                                                                754 MD     2005/06
                                                                                                                     Other Proposed Insured
759 FL    2005/06   Florida Notice to Applicant Regarding Replacement of Life Insurance
                                                                                                                     Maryland Life Insurance Application Supplement - Additional
966 FL    2007/03   Florida Annuity Product Comparison Form                                     755 MD     2004/09
                                                                                                                     Owners
                    Florida Annuity Product Comparison Form Supplement - Policy / Rider                              Maryland Life Insurance Application Supplement - Additional
969 FL    2007/03                                                                               756 MD     2004/09
                    Description                                                                                      Beneficiaries

                                          Georgia                                               759 MD     2005/06   Maryland Important Notice Regarding Replacement
757 GA    2004/12   Georgia HIV Antibody/Antigen Consent and Testing Form                                            Maryland Policy Effective Date Supplement - Date of Policy
                                                                                                761 MD     2005/04
                                                                                                                     Application
                                           Hawaii
                                                                                                                     Maryland Policy Effective Date Supplement - Date of Policy
759 HI    2007/03   Hawaii Important Notice Regarding Replacement                               762 MD     2005/04
                                                                                                                     Delivery

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

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


ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 05-31-2011)
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/Health Forms - Available ONLY on the ACORD Web Site
                                                                                STATE LIFE FORMS - continued
 Number   Edition   Title                                                                          Number   Edition   Title
                                    Massachusetts                                                                                             Ohio
701 MA    2004/08   Massachusetts Simplified Issue Life Insurance Application - Part 1            757 OH    2009/02   Ohio HIV Antibody/Antigen Consent and Testing Form
702 MA    2004/08   Massachusetts Life Insurance Application - Part 2 Medical History                                                       Oregon
753 MA    2004/08   Massachusetts Notice of Insurance Information Practices (Pre Notice)          757 OR    2004/07   Oregon HIV Antibody/Antigen Consent and Testing Form

754 MA    2004/08
                    Massachusetts Simplified Issue Life Insurance Application Supplement -                                              Pennsylvania
                    Additional Other Proposed Insured
                                                                                                  701 PA    2004/06   Pennsylvania Life Insurance Application - Part 1
                    Massachusetts Simplified Issue Life Insurance Application Supplement -
755 MA    2004/08                                                                                 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    2010/12   Virginia 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    2010/05   Washington HIV Antibody/Antigen Consent and Testing Form
761 MO    2004/08   Missouri Policy Effective Date Supplement - Date of Policy Application        760 WA    2005/09   Washington Important Notice Regarding Replacement
762 MO    2004/08   Missouri Policy Effective Date Supplement - Date of Policy Delivery                                                 West Virginia
763 MO    2004/08   Missouri Policy Effective Date Supplement - Date Policy Issued                757 WV    2004/07   West Virginia HIV Antibody/Antigen Consent and Testing Form
767 MO    2004/11   Missouri Temporary Insurance Agreement                                                                                Wisconsin
                                    New Hampshire                                                 702 WI    2004/10   Wisconsin Life Insurance Application - Part 2 Medical History
757 NH    2004/07   New Hampshire HIV Antibody/Antigen Consent and Testing Form                   757 WI    2005/03   Wisconsin HIV Antibody / Antigen Consent and Testing Form

                                        New York                                                  767 WI    2004/07   Wisconsin Temporary Insurance Agreement
751 NY    2005/11   New York Authorization to Obtain and Disclose Information                                         Wisconsin Life Insurance Application - Part 2 Medical History Medical
                                                                                                  768 WI    2004/10
                                                                                                                      Condition Details / Additional Care Providers
753 NY    2005/11   New York Notice of Insurance Information Practices (Pre Notice)
757 NY    2005/11   New York HIV Antibody/Antigen Consent and Testing Form
                    New York Important Notice Regarding Replacement or Change of Life
760 NY    2007/03
                    Insurance Policies or Annuity Contracts
                    New York Disclosure Statement Regarding Replacement of Life Insurance
775 NY    2007/03
                    Policies or Annuity Contracts
776 NY    2007/03   New York Definition of Replacement
960 NY    2007/03   New York Disclosure Statement Annuity to Annuity Replacements Only

                                     North Carolina
751 NC    2006/02   North Carolina Authorization to Obtain and Disclose Information
767 NC    2004/12   North Carolina Temporary Insurance Agreement




ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                   ACORD Forms Index (rev. 05-31-2011)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                    Page 10 of 10

				
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