forms index october r2 - acord.org

ACORD Forms Index Please provide the information below to avoid delay in shipment.

Agency/Company Name: Contact Name:

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All packages contain 100 forms –Please specify number of packages required

COUNTRYWIDE P&C FORMS

Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2016/01 for use on or after 1/1/2016) ACORD Member Services – Phone: (845) 620-1700 ACORD Forms Index (rev. 12/7/2021) All forms are available for download on the ACORD web site (http://www.acord.org) of 13

# Current Future Title Quantity 1 2019/07 Property Loss Notice 2 2019/07 Automobile Loss Notice 3 2019/09 Liability Notice of Occurrence / Claim

4 2019/09

Workers Compensation – First Report of Injury or Illness

5 2019/09 Aircraft Loss Notice 6 2009/05 Aviation Witness / Passenger Schedule 7 2009/05 Aviation Injured Schedule 11 2/95 Auto Accident Information Form 12 2/95 Exchange of Information Form 13 2/95 Witness Card 20 2016/03 Certificate of Aviation Liability Insurance 21 2016/03 Certificate of Aircraft Insurance 22 2016/03 Intermodal Interchange Certificate of Insurance 23 2016/03 Vehicle or Equipment Certificate of Insurance 24 2016/03 Certificate of Property Insurance 25 2016/03 Certificate of Liability Insurance 26 2002/01 Policy Certification Log 27 2016/03 Evidence of Property Insurance 28 2016/03 Evidence of Commercial Property Insurance 29 2016/03 Evidence of Flood Insurance 30 2016/03 Certificate of Garage Insurance 31 2016/03 Certificate of Marine / Energy Insurance 35 2017/05 Cancellation Request / Policy Release 36 2007/01 Agent/Broker of Record Change 37 2008/01 Statement of No Loss 38 2013/01 Notice of Insurance Information Practices (Privacy) 42 2014/08 Residential Property Replacement Cost 45 2016/03 Additional Interest Schedule 50 2007/02 Automobile Insurance ID Card 50 WM

2007/03 Automobile Insurance ID Card (with Watermark)

54 1/97 Financial Responsibility Form 57 1/97 Financial Responsibility Form – Cancellation 58 2007/11 Notice of Cancellation or Termination of Policy 60 2010/04 Flood Insurance Selection / Rejection

60 US 2015/01 Insurance Supplement – Notice – Offer of

Terrorism Coverage

62 US 2015/01 Insurance Supplement – Standard Fire Policy Only

Notice – Offer of Terrorism Coverage

63 2016/10 Fraud Statements

64 US 2015/01 Insurance Supplement – Workers’ Compensation

Only Notice – Offer of Terrorism Coverage

# Current Future Title Quantity

66 2011/05 Personal Insurance Supplement - Extraordinary

Life Circumstances

68 2019/06 Electronic Delivery Supplement – Electronic Selection, Rejection Form

70 2015/09 Personal Policy Change Request (Except Auto) 71 2016/08 Personal Auto Policy Change Request 72 2009/10 Mobile Home Supplement

73 2009/07 Solid Fuel Questionnaire – Supplement to Residential Section

74 2009/09 Residence Based Business

Supplement to Residential Section

75 2016/03 Insurance Binder 76 9/93 Binder Log 80 2016/11 Homeowner Application 81 2016/03 Personal Inland Marine Application 82 2020/03 Watercraft Application 83 2016/04 Personal Umbrella Application 84 2016/11 Dwelling Fire Application 85 2016/11 Mobile Home Application

88 2015/12 Personal Insurance Application – Applicant Information Section

89 2016/11 Residential Section 91 2009/10 Good Student Driver Training 92 2012/03 Medical Statement 93 2016/08 Young Driver Questionnaire 99 2009/02 Accidents / Convictions Schedule 101 2008/01 Additional Remarks Schedule

103 2012/03 Personal Auto Application Schedule – Additional Resident and Driver Information Section

105 2012/06 Apartment Building Supplement 106 2010/04 Vacant Building Supplement

125 2016/03 Commercial Insurance Application

Applicant Information Section

126 2016/09 Commercial General Liability Section 127 2015/12 Business Auto Section 128 2015/12 Garage and Dealers Section 129 2009/11 Vehicle Schedule 130 2017/05 Workers Compensation Application 131 2017/11 Umbrella Section 132 2015/12 Truckers / Motor Carriers Section

133 2017/12 Workers Compensation Insurance Plan –

Assigned Risk Section

139 2015/12 Statement / Schedule of Values 140 2016/03 Property Section

ACORD Forms Index All packages contain 100 forms –Please specify number of packages required

COUNTRYWIDE P&C FORMS - continued


# Current Future Title Quantity 141 2016/03 Crime Section 143 2013/09 Transportation Section 144 2013/09 Glass and Sign Section 145 2013/09 Accounts Receivable / Valuable Papers 147 2016/03 Installation / Builders Risk Section 148 2016/03 Electronic Data Processing Section 14e9 2013/09 Dealers Section 152 2015/06 Commercial Inland Marine Section 155 2016/09 Equipment Breakdown Section 159 2014/09 Schedule of Property Limits 160 2016/09 Business Owners Section 163 2012/06 Commercial Auto Driver Information Schedule 175 2016/03 Commercial Policy Change Request

180 2016/03 Technology E&O Section – Electronic Data

Processors, Electric Products Manufacturers, Computer Services etc.

185 2011/09 Restaurant / Tavern Supplement 186 2011/10 Contractors Supplement 187 2016/03 Professional Liability Supplement 190 2013/09 Supplemental Property Application 193 2013/09 Open Cargo Section 194 2009/03 Truckers / Motor Carrier Supplement 195 10/96 Design Professional’s Individual Property Survey 196 2013/09 Medical Professional Liability Insurance Application 199 1/99 Application Supplement – Undertaking 200 3/93 Producer Account 201 3/93 Producer Account Discrepancy Notice 210 2016/03 Yacht Section 211 2016/09 Schedule of Hazards 212 2017/09 Commercial Umbrella Underlying Schedule 225 1/98 Policyholder’s Report 226 3/93 Statement of Premium Adjustment 275 2016/03 Aviation Insurance Binder 276 2016/03 Aircraft Insurance Binder 281 2016/05 Personal Inland Marine Section 282 2016/05 Watercraft Section 283 2016/04 Personal Umbrella Application Section

301 2015/04 National Flood Insurance Program

Flood Insurance Application

302 2015/04 NFIP – Flood Insurance General Change Endorsement

303 2015/04 NFIP – Flood Insurance Preferred Risk Policy

Application

304 2018/08 NFIP – Flood Insurance Cancellation / Nullification 305 2012/02 NFIP – Credit Card Payment Form

306 2011/04 NFIP – Rating Information and Elevated Building Determination Form

307 2016/02 NFIP – Floodproofing Certificate for Non-Residential

Structures

308 2015/04 NFIP – Residential Basement Floodproofing Certificate

325 2013/09 Aviation Insurance Application – Applicant

Information Section

326 2006/04 Airport Property Supplement 327 2016/03 Airport and FBO Liability Section 328 2014/12 Private Hanger Liability Section 329 2014/12 Aviation Products Liability 330 2016/03 Aircraft Section 331 2011/11 Pilot Experience 332 2006/04 Hanger Schedule 333 2009/05 Aircraft Schedule

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

336 2009/06 Airport Property Change Request 337 2016/03 Airport and FBO Liability Change Request 338 2009/06 Private Hangar Liability Change Request 339 2009/06 Aviation Products Liability Change Request 340 2016/03 Aircraft Change Request 341 2011/11 Pilot Experience Change Request

# Current Future Title Quantity 342 2009/06 Hanger Change Request 350 Watermark Paper – 20 # ID Card Stock (4-part

perforation)

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

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

401 2016/03 Agriculture Application 402 2016/03 Agriculture Property Section

403 2016/03 Agriculture Property Section

Scheduled / Unscheduled Personal Property

404 2016/03 Agriculture Liability Section 405 2007/09 Agriculture Premises Diagram

406 2007/09 Agriculture Supplement- Unscheduled Farm

Personal Property Inventory Form

407 2016/03 Livestock Mortality Section 408 2007/09 Equine Liability Supplement 410 2016/03 Small Farm / Ranch Application 501 2016/06 Surety Report of Execution 502 2018/08 Contract Bond Request Form

503 2016/06 Commercial or Miscellaneous Bond Request Form

504 2016/06 Additional Entity Schedule 610 2015/12 Premium Payment Supplement 611 2015/07 Claims History / Loss Run Request 801 2002/01 Railroad Protective Liability Supplement 802 2011/09 Hotel / Motel Supplement 803 2016/03 Liquor Liability Section 807 2016/03 Directors & Officers Liability Section 808 2010/08 P&C Agency Appointment Form

810 2014/12 Business Income / Extra Expense / Rental Value

Supplement to Property Section

811 2014/12 Value Reporting Information Supplement to Property Section

812 2006/02 Agency Questionnaire 813 2005/03 Request for Proof of Property Insurance 815 2009/02 International Liability Exposure Supplement 816 2005/06 International Property Exposure Supplement 821 2015/10 Producer Information Form (PIF)

822 2009/07 Driver Work / School Address Information

Supplement

823 2015/12 Additional Premises Information Schedule

825 2016/05

Professional / Specialty Insurance Application – For Use in Management, Executive & Professional Lines Applicant Section

827 2016/03 Employment Practices Liability Insurance Section 828 2016/03 Fiduciary Liability Coverage Section 829 2009/05 Forms and Endorsements Schedule 830 2008/11 Property Insurance Card

831 2019/09 Professional / Specialty Insurance Notice of Incident / Claim

832 2016/03 Miscellaneous E&O Section 833 2014/12 Lawyers Professional Liability Section 834 2014/12 Cyber and Privacy Coverage Section 838 2013/12 Accountants Professional Liability Section 876 2015/10 Background Check Authorization

877 2015/10 Disclosure of Intent to Obtain Consumer Report

or Investigative Consumer Report (except California)


STATE P&C FORMS


# Current Future Title Quantity Alabama

50 AL 2007/10 Alabama Insurance Identification Card 62 AL 5/98 Alabama Insurance Application Supplement 90 AL 2015/12 Alabama Personal Auto Application 137 AL 2015/12 Alabama Commercial Auto 138 AL 2015/12 Alabama Garage and Dealers 290 AL 2014/12 Alabama Personal Automobile Application Section

Alaska

61 AK 7/97 Alaska Auto Supplement – UM/UIM Coverage Selection

62 AK 2/98 Alaska Auto Supplement – Exclusion of Named

Drivers

90 AK 2015/12 Alaska Personal Auto Application 137 AK 2015/12 Alaska Commercial Auto 138 AK 2015/12 Alaska Garage and Dealers 171 AK 6/98 Alaska Petition for Executive Officer Waiver 290 AK 2014/12 Alaska Personal Auto Application Section

Arkansas 50 AR 2007/10 Arkansas Proof of Insurance Card 61 AR 2010/04 Arkansas Auto Supplement UM/UIM Coverage 62 AR 2013/09 Arkansas Personal Umbrella Supplement

67 AR 2000/02 Arkansas Property Supplement – Declination of

Residential Earthquake Coverage

90 AR 2015/12 Arkansas Personal Auto Application 137 AR 2015/12 Arkansas Commercial Auto 138 AR 2015/12 Arkansas Garage and Dealers 180 AR 2016/03 Arkansas Technology E&O Section 290 AR 2014/12 Arkansas Personal Auto Application Section 807 AR 2016/03 Arkansas Directors & Officer Liability Section

827 AR 2016/03 Arkansas Employment Practices Liability

Insurance Section

828 AR 2016/03 Arkansas Fiduciary Liability Coverage Section 832 AR 2016/03 Arkansas Miscellaneous E&O Section 833 AR 2014/12 Arkansas Lawyers Professional Liability Section 834 AR 2014/12 Arkansas Cyber and Privacy Coverage Section

838 AR 2013/12 Arkansas Accountants Professional Liability

Section

Arizona 38 AZ 2003/10 Arizona Notice of Information Practices (Privacy) 50 AZ 2018/08 Arizona Insurance Identification Card

61 AZ 2020/07 Arizona Auto Supplement UM/UIM Coverage

Selection

90 AZ 2016/08 Arizona Personal Auto Application 137 AZ 2015/12 Arizona Commercial Auto 138 AZ 2015/12 Arizona Garage and Dealers 290 AZ 2016/08 Arizona Personal Automobile Application Section

California

42 CA 2019/07 California Residential Personal Property

Replacement Cost Notice

50 CA 2004/07 California Insurance Identification Card 51 CA 2004/07 California Evidence of Liability Insurance 52 CA 2007/07 California Fleet Auto Insurance Identification Card

61 CA 2008/03 California Auto Supplement – Mandatory UM

Bodily Injury / Property Damage Coverage Offer

64 CA 2004/02 California Insurance Supplement – Agency Language

65 CA 2020/01 California Insurance Supplement – Race, National

Origin, Gender

66 CA 2017/01 California Offer of Earthquake Coverage

67 CA 2021/02 California Residential Property Insurance

Disclosure

68 CA 2001/03 California Scheduled Personal Property Loss Computation Disclosure

69 CA 2013/10 California Insurance Supplement

70 CA 2020/07 California Earthquake Supplement - Applicable to Coverage Renewals

90 CA 2015/12 California Personal Auto Application 130 CA 2019/01 California Workers Compensation Application 137 CA 2015/12 California Commercial Auto 138 CA 2016/02 California Garage and Dealers

177 CA 2015/09 California Auto Body Repair Consumer Bill of Rights

# Current Future Title Quantity California (continued)

290 CA 2014/12 California Personal Auto Application Section

854 CA 2021/05 California FAIR Plan Property Insurance –

Application for Dwelling Insurance


Application for Commercial Insurance


Application for Businessowners (BOP) Insurance

857 CA 2011/02 California Earthquake Authority – Application

for Earthquake Insurance

860 CA 2004/12 California Auto Supplement – Driver Self

Certification

861 CA 2011/07 California Residential Property Insurance Bill of Rights

877 CA 2015/10 California Disclosure of Intent to Obtain an

Investigative Consumer Report

Colorado 38 CO 2019/07 Colorado Model Privacy Form with Opt-Out 39 CO 2019/07 Colorado Model Privacy Form with No Opt-Out 50 CO 2007/03 Colorado Insurance Identification Card

61 CO 2018/04 Colorado Auto Supplement – Summary of

Coverages

64 CO 2009/01 Colorado Auto Supplement –Colorado Offer of Medical Payments Coverage

65 CO 2013/02 Colorado Personal Property Supplement –

Summary of Coverage Renters Policy


Summary of Coverage Condominium Policy

67 CO 2013/02 Colorado Personal Property Supplement – Summary of Coverage Dwelling Fire Policy


Summary of Coverage Homeowners Policy


Homeowner’s Insurance Replacement-Cost Policy Applicants

90 CO 2015/12 Colorado Personal Automobile Application 137 CO 2015/12 Colorado Commercial Auto 138 CO 2015/12 Colorado Garage and Dealers

171 CO 2006/01 Colorado Rejection of Coverage by Corporate Officers

290 CO 2014/12 Colorado Personal Automobile Application

Section

Connecticut 50 CT 2009/01 Connecticut Insurance Identification Card 61 CT 2018/01 Connecticut Auto Supplement – UM Coverage

62 CT 2011/07 Connecticut Personal Insurance Supplement –

Summary of Consumer Protections

66 CT 2015/02 Connecticut FAIR Plan Application for Property

/ Liability Insurance

90 CT 2015/12 Connecticut Personal Auto Application 137 CT 2015/12 Connecticut Commercial Auto 138 CT 2015/12 Connecticut Garage and Dealers

171 CT 2020/09

Connecticut Workers’ Comp. Comm. – Coverage Election by Employee who is an Officer of a Corporation, Manager of an LLC, or Member of a Multiple-Member LLC

172 CT 2020/09 Connecticut Workers’ Com. Comm. – Coverage

Election by Employees who are Members of a Partnership

173 CT 2020/09 Connecticut Workers’ Com. Comm. – Coverage

Election by Sole Proprietor or Single-Member LLC

290 CT 2014/12 Connecticut Personal Automobile Application Section


STATE P&C FORMS - continued


1/29/2019

# Current Future Title Quantity Delaware

37 DE 2019/07 Delaware Renewal Notice: Right for Credit

Information Review

38 DE 2021/07

Delaware Personal Insurance Supplement: Use of Credit Information

39 DE 2019/07 Delaware Privacy Notice for Excess Lines Broker

or Excess Lines Insurer

61 DE 2018/06 DE Auto Supplement, DE Motorist’s Protection Act Required Statement to Policyholders

62 DE 2004/10 DE Auto Supplement, PIP Deductible Options

64 DE 2015/05 Insurance Placement Facility of Delaware Basic Property Insurance Application

65 PA / DE/WV

2015/05

FAIR Plan Supplementary Questionnaire

67 DE 2012/01 Delaware Insurance Supplement 90 DE 2021/03 Delaware Personal Auto Application 137 DE 2015/12 Delaware Commercial Auto 138 DE 2015/12 Delaware Garage and Dealers 171 DE 2006/01 Delaware Executive Officer(s) Exclusion 290 DE 2021/03 Delaware Personal Auto Application Section

District of Columbia

62 DC 2013/09 District of Columbia Personal Property

Supplement, Statement Regarding Flood Insurance

64 DC 2017/02 Application to District of Columbia Property

Insurance Facility for Basic Property Insurance

66 DC 2017/02 District of Columbia Property Ins. Facility –

Essential Homeowners Ins. Inspection and Placement p. 1

67 DC 2017/02 District of Columbia Property Ins. Facility –

Essential Homeowners Ins. Inspection and Placement Application p. 2

68 DC 2013/09 District of Columbia Personal Property

Supplement, Statement Regarding Sewer-line Backup Insurance

90 DC 2015/12 District of Columbia Personal Auto Application 137 DC 2015/12 District of Columbia Commercial Auto 138 DC 2015/12 District of Columbia Garage and Dealers 290 DC 2014/12 District of Columbia Personal Auto App Section

Florida 50 FL 2017/12 Florida Auto ID Card

61 FL 2011/10 Florida Auto Supplement – Rejection/Election of UM Coverage

62 FL 2013/12 Florida Auto Supplement – Personal Injury

Protection Options

64 FL 2011/10 Florida Auto Supplement – Notice to

Policyholders – Florida Notification of Availability of Uninsured Motorist Coverage

65 FL 2007/08 Florida Residential Property Supplement

66 FL 2013/12 Florida Insurance Supplement Credit Report Disclosure Information

67 FL 2020/08 Florida Homeowners Notice 68 FL 2019/07 Florida Residential Flood Property Supplement

70 FL 2012/02 Florida Property Supplement

Uniform Mitigation Verification Inspection Form

80 FL 2021/06 Florida Homeowner Application 83 FL 2014/12 Florida Personal Umbrella Application 90 FL 2015/12 Florida Personal Auto Application

125 FL 2016/03 Florida Commercial Insurance Application

Applicant Information

130 FL 2019/07 Florida Workers Compensation Application 133 FL 2020/01 Florida Workers Comp. Addendum to ACORD 130 FL 137 FL 2015/12 Florida Commercial Auto 138 FL 2015/12 Florida Garage and Dealers 171 FL 2014/10 Florida Notice of Election of Coverage 172 FL 2007/08 Florida Revocation of Election to be Exempt 174 FL 2007/08 Florida Revocation of Election of Coverage 175 FL 3/97 Florida W C Monthly Change Sheet

220 FL 2012/12 Citizens Property Insurance Corporation

Commercial – Residential Wind Only

# Current Future Title Quantity Florida (continued)

221 FL 2002/07 Citizens Property Ins. Corp. Wind Only –

Supplemental Application Schedule Commercial and Commercial – Residential

283 FL 2014/12 Florida Personal Umbrella Application Section 610 FL 2021/06 Florida Premium Payment Supplement 860 FL 2011/11 Florida Commercial Auto Addendum 862 FL 2013/12 Florida Personal Auto Supplement 863 FL 2013/12 Florida Personal Auto Supplement

Georgia

9 GA 2019/10 Georgia Notice of Nonrenewal of Motor Vehicle

Insurance

10 GA 2019/10 Georgia Notice of Nonrenewal of Motor Vehicle Insurance Based on Termination of Agency

50 GA 2008/11 Georgia Insurance Policy Information Card 51 GA 2005/01 Georgia Fleet Policy Information Card

64 GA 2009/01 Georgia Auto Supplement – Georgia Auto

Disclosure Form, Notice to Policyholders, Uninsured Motorist Coverage Selection

90 GA 2015/12 Georgia Personal Auto Application 137 GA 2015/12

Georgia Commercial Auto

138 GA

2015/12 Georgia Garage and Dealers

171 GA 2013/05

Georgia State Board of Workers’ Compensation – Notice of Election or Rejection of Workers’ Compensation Coverage

290 GA 2014/12

Georgia Personal Automobile Application Section




# Current Future Title Quantity Hawaii

50 HI 2008/01 Hawaii Auto ID Card 60 HI 2010/07 Hawaii Auto Supplement – UM/UIM/PIP 90 HI 2015/12 Hawaii Personal Auto Application 94 HI 2001/03 Hawaii Vehicle Inspection Report Supplement 137 HI 2015/12 Hawaii Commercial Auto 138 HI 2015/12 Hawaii Garage and Dealers 290 HI 2015/12 Hawaii Personal Auto Application Section

Idaho

50 ID 2007/10 State of Idaho Liability Insurance Identification

Card

61 ID 2019/01 Idaho Auto Supplement – Idaho Uninsured

Motorist and Underinsured Motorist Disclosure Statement

90 ID 2019/01 Idaho Personal Auto Application 137 ID 2015/12 Idaho Commercial Auto 138 ID 2015/12 Idaho Garage and Dealers 290 ID 2014/12 Idaho Personal Automobile Application Section

Illinois 50 IL 2007/03 Illinois Insurance Identification Card 61 IL 2019/1 Illinois Auto Supplement – UM/UIM

62 IL 2007/08 Illinois Property Supplement – Notice of

Availability of Earthquake Insurance

67 2017/01 Illinois / Indiana/ Kentucky/ West Virginia Mine Subsidence Property Insurance Supplement

67 IL 2012/01 Illinois Insurance Supplement – Civil Union

Disclosure

90 IL 2015/12 Illinois Personal Auto Application 137 IL 2015/12 Illinois Commercial Auto 138 IL 2015/12 Illinois Garage and Dealers

171 IL 2005/06 Illinois FAIR Plan Application for Commercial

Property Insurance

290 IL 2014/12 Illinois Personal Auto Application Section Indiana

50 IN 2007/11 Indiana Insurance Identification Card


90 IN 2019/01 Indiana Personal Auto Application 137 IN 2015/12 Indiana Commercial Auto 138 IN 2015/12 Indiana Garage and Dealers 290 IN 2014/12 Indiana Personal Auto Application

Iowa 50 IA 2007/08 Iowa Financial Responsibility Card 61 IA 2002/02 Iowa Auto Supplement – UM/UIM Offer/Rejection

62 IA 2/98 Iowa Auto Supplement – Notice regarding UM/UIM Coverage

64 IA 2/98 Iowa Auto Supplement – UM/UIM Stacking

coverage Notice

65 IA 2008/01 Iowa Auto Supplement – Aftermarket Crash Parts

66 IA 2006/07 Iowa Personal Insurance Supplement

Disclosure Use of Claims History

67 IA 2010/07 Iowa Personal Insurance Supplement

Extraordinary Life Circumstances Disclosure

90 IA 2015/12 Iowa Personal Auto Application 137 IA 2015/12 Iowa Commercial Auto 138 IA 2015/12 Iowa Garage and Dealers

290 IA 2014/12 Iowa Personal Automobile Application Section

# Current Future Title Quantity Kansas

38 KS 2013/12 Kansas Personal Insurance Supplement – Notice

of Insurance Information Practices

90 KS 2016/04 Kansas Personal Auto Application 137 KS 2016/04

Kansas Commercial Auto

138 KS

2016/04 Kansas Garage and Dealers

171 KS 2020/09

Kansas Election Of Individual, Partner or Self-Employed Individual

172 KS

2020/09 Kansas Cancel. Of Election Of Individual, Partner or Self-Employed Individual

173 KS

2020/09 Kansas Cancel. of Election Not to Accept

Coverage

174 KS 2020/09

Kansas Election Not to Accept Coverage

176 KS

2020/09 Kansas Election of Employer to Cover Employees

177 KS 2020/09

Kansas Election of Coverage for Volunteer Workers

178 KS

2020/09 Kansas Cancel. Of Election of Employer to Cover Employees

179 KS 2020/09

Kansas Cancel. Of Election of Coverage for Volunteer Workers

180 KS

2020/09 Kansas Election of Coverage for Persons Performing Public Service

181 KS

2020/09 Kansas Cancel. Of Election of Coverage for

Persons Performing Public Service

182 KS 2020/09

Kansas Election of a Noncompensated Volunteer to be Covered

183 KS

2020/09 Kansas Cancel. of Election of a Noncompensated Volunteer to be Covered

290 KS 2016/04

Kansas Personal Auto Application Section

Kentucky 50 KY 2006/01 Commonwealth of Kentucky Proof of Insurance

60 KY 2017/11 Kentucky Auto Supplement – Rejection of Uninsured / Underinsured Motorist Coverage

64 KY 2011/01 Kentucky FAIR Plan Homeowners Application 65 KY 2011/01 Kentucky FAIR Plan Dwelling Fire Application 66 KY 2011/01 Kentucky FAIR Plan Farm Fire Application

67 2017/01 Illinois / Indiana/ Kentucky/ West Virginia Mine

Subsidence Property Insurance Supplement

68 KY 2011/01 Kentucky FAIR Plan Commercial Fire Application 90 KY 2015/09 Kentucky Personal Auto Application 137 KY

2015/09 Kentucky Commercial Auto

138 KY 2015/09

Kentucky Garage and Dealers

290 KY

2015/09 Kentucky Personal Auto Application Section




# Current Future Title Quantity Louisiana

50 LA 2018/10 Louisiana Auto Insurance Identification Card

60 LA 4/98 Louisiana Dwelling Supplement – Loss Settlement

DWG1

61 LA 2001/05 Louisiana Homeowners Supplement – Loss

Settlement (HO4)

62 LA 4/98 Louisiana Commercial Property Supplement

64 LA 2001/05 Louisiana Homeowners Supplement

Loss Settlement (HO2 & 3)

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

66 LA 4/98 Louisiana Dwelling Supplement – Loss Settlement

DWG2 & 3

67 LA 5/98 Louisiana Certification of Mobile Home Tie Downs 68 LA 4/98 Louisiana Plan Services Application for Insurance 90 LA 2015/12 Louisiana Personal Auto Application 137 LA 2015/12 Louisiana Commercial Auto 138 LA 2015/12 Louisiana Garage and Dealers 290 LA 2014/12 Louisiana Personal Auto Application Section

861 LA 2005/07 Louisiana Auto Supplement – Active Military

Personnel Affidavit

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

Maine

50 ME 2007/08 2022/1 Maine Motor Vehicle Insurance Identification Card

51 ME 2022/1 Maine Temporary Motor Vehicle Insurance

Identification Card

90 ME 2015/12 Maine Personal Auto Application 137 ME 2015/12 Maine Commercial Auto 138 ME 2015/12 Maine Garage and Dealers 290 ME 2015/12 Maine Personal Auto Application Selection

Maryland

36 MD 2020/05 Maryland Change of Insurance Producer of Record

39 MD 2016/05 Maryland Personal Insurance Supplement

50 MD 2016/10 Maryland Motor Vehicle Liability Insurance Identification Card

62 MD 1/98 Maryland Commercial Auto Supplement

64 MD 2017/02 Maryland Property Insurance Availability Program

Essential Property Insurance Inspection and Placement


– Essential Homeowners Insurance Inspection an Placement (p. 1 of 2)


– Essential Homeowners Insurance Inspection an Placement (p. 2 of 2)

67 MD 2018/07

Maryland Personal Auto Supplement – Mandatory Offer of Increased Liability Coverage for Claims of Family Members, Mandatory PIP Waiver, and Mandatory UM Coverage Waiver

68 MD 2007/01 Maryland Personal Property Supplement – Statement Regarding Flood Insurance

69 MD 2013/10 Maryland Insurance Supplement – Notice of

Underwriting Period

90 MD 2019/08 Maryland Personal Auto Application

95 MD 2018/07 Maryland Required Notice of UM Coverage and

Enhanced Motorist (“EUIM”) Coverage and Option Selection Form

137 MD 2015/12 Maryland Commercial Auto 138 MD 2015/12 Maryland Garage and Dealers

290 MD 2018/08 Maryland Personal Automobile Application

Section

851 MD 2008/11 Maryland Personal Property Supplement – Loss

from Water and Sewer Backup

852 MD 2012/10 Maryland Personal Property Supplement –

Homeowner’s Insurance, Limitation of Claims Made Notice

853 MD 2014/01 Maryland Personal Property Supplement

# Current Future Title Quantity Massachusetts

60 MA 2020/11 Massachusetts Property Insurance Underwriting

Association Application for Homeowners Insurance


Association Instructions to Complete Homeowners Application ACORD 60 MA

64 MA 2/97 Massachusetts Residential Property Liability

Supplement Lead Poisoning Liability Disclosure Notice


Association Application for Dwelling Fire and Liability Insurance Inspection and Placement

66 MA 2015/01 Massachusetts Property Ins. Underwriting Assn.

– Instructions for Completing Dwelling Fire and Liability Insurance Inspection and Placement

67 MA 2003/04 Massachusetts Property Ins. Underwriting Assn.

– Application for Commercial Fire Insurance Inspection and Placement

68 MA 2003/04

Massachusetts Property Ins. Underwriting Assn. Inspection Notice, Credit Reporting notice and Instructions for Completing Commercial Fire Application ACORD 67 MA

69 MA 2010/07 Massachusetts Residential Property Liquid Fuel Spill Supplement

90 MA 2016/09 Application for Massachusetts Motor Vehicle

Insurance

95 MA 2009/12 Massachusetts Renewal Application (Statement

of Facts)

137 MA 2015/12 Massachusetts Commercial Auto 138 MA 2015/12 Massachusetts Garage and Dealers

Michigan

50 MI 2010/08 State of Michigan Certificate of No-Fault Insurance

60 MI 2010/03 Michigan Automobile Insurance Placement

Facility: Michigan Auto Supplement – Declaration of Intent to Reside

61 MI 2020/07 Michigan Choice of Bodily Injury Liability

Coverage Limits

62 MI 2020/07 Michigan Collision Insurance Options Notice

64 MI 2000/10 Michigan Basic Property Insurance Assn.

Insurance Application

66 MI 2020/07 Michigan Selection of Personal Injury Protection (PIP) Medical Coverage - Individual

90 MI 2020/07 Michigan Personal Auto Application

133 MI 2012/08 Michigan Application for Workers’ Compensation Insurance

136 MI 2020/07 Michigan Selection of Personal Injury Protection

(PIP) Medical Coverage - Commercial Business

137 MI 2020/07 Michigan Commercial Auto Coverages (Coverages/Limits Section)

138 MI 2020/07 Michigan Garage and Dealers

139 MI 2004/07

Michigan Automobile Insurance Placement Facility Supplement to ACORD App. – Application for Commercial, Public Automobiles and Corporately Owned Vehicles

171 MI 2005/01 Michigan Notice of Election

172 MI 4/96 Michigan Application for Exclusion of Partner(s),

Spouse, Child or Parent

173 MI 2000/09 Michigan WC Placement Facility Specific Person Exclusion

290 MI 2020/07 Michigan Personal Automobile Application

Section

860 MI 2020/07 Michigan Auto Supplement – Declaration of Intent to Reside




# Current Future Title Quantity Minnesota

38 MN 2021/08 Minnesota Authorization 62 MN 2000/01 Minnesota Auto Supplement

65 MN 2020/10 Minnesota Insurance Guarantee Association

Notice

90 MN 2019/12 Minnesota Personal Auto Application 137 MN 2015/12 Minnesota Commercial Auto 138 MN 2015/12 Minnesota Garage and Dealers 290 MN 2019/12 Minnesota Personal Auto Application Section

807 MN 2016/03 Minnesota Directors & Officers Liability Insurance Section

827 MN 2016/03 Minnesota Employment Practices Liability

Insurance Section

828 MN 2016/03 Minnesota Fiduciary Liability Coverage Section 832 MN 2016/03 Minnesota Miscellaneous E&O Section 833 MN 2014/12 Minnesota Lawyers Professional Liability Section 834 MN 2014/12 Minnesota Cyber and Privacy Coverage Section

838 MN 2013/12 Minnesota Accountants Professional Liability Section

853 MN 2010/08 Minnesota Homeowners Personal Property

Supplement

Mississippi 50 MS 2008/01 Mississippi Auto Insurance ID Card

61 MS 2013/07 Mississippi Auto Supplement – Non-Stacking

UM Insurance

62 MS 2016/07 Mississippi Auto Supplement – Selection /

Rejection of Uninsured Motorist Insurance

66 MS 2016/11 Mississippi Insurance Supplement 90 MS 2016/07 Mississippi Personal Auto Application 137 MS 2016/07 Mississippi Commercial Auto 138 MS 2016/07 Mississippi Garage and Dealers 139 MS 2/99 Mississippi Statements/Schedule of Values 290 MS 2016/07 Mississippi personal Auto Application Section

Missouri 50 MO 2007/05 Missouri Auto Insurance ID Card

62 MO 2007/08 Missouri Property Supplement – Notice of Availability Earthquake Insurance

67 MO 2009/06 Missouri FAIR Plan Insurance Application 90 MO 2015/12 Missouri Personal Auto Application 137 MO 2015/12 Missouri Commercial Auto 138 MO 2015/12 Missouri Garage and Dealers 290 MO 2014/12 Missouri Personal Auto Application Section

Montana

60 MT 2003/09 Montana Application Supplement – Refusal to

Renew

90 MT 2015/12 Montana Personal Auto Application 137 MT 2015/12 Montana Commercial Auto 138 MT 2015/12 Montana Garage and Dealers 290 MT 2015/12 Montana Personal Auto Application Section 807 MT 2016/03 Montana Directors & Officers Liability Section

827 MT 2016/03 Montana Employment Practices Liability

Insurances Section

828 MT 2016/03 Montana Fiduciary Liability Coverage Section 832 MT 2016/03 Montana Miscellaneous E&O Section 833 MT 2014/12 Montana Lawyers Professional Liability Section 834 MT 2014/12 Montana Cyber and Privacy Coverage Section

838 MT 2013/12 Montana Accountants Professional Liability

Section

Nebraska

50 NE 2007/01 Nebraska Auto Liability Insurance Identification

Card

90 NE 2015/12 Nebraska Personal Auto Application 137 NE 2015/12 Nebraska Commercial Auto 138 NE 2015/12 Nebraska Garage and Dealers 290 NE 2014/12 Nebraska Personal Auto Application

# Current Future Title Quantity Nevada

51 NV 2016/07 Nevada Temporary Insurance Identification Card 52 NV 2016/07 Nevada Permanent Insurance Identification Card

53 NV 2016/07 Nevada Temporary Insurance Identification

Card, Evidence of Operator’s Policy of Liability Insurance

54 NV 2016/07 Nevada Permanent Insurance Identification

Card, Evidence of Operator’s Policy of Liability Insurance

61 NV 2021/10 Nevada Auto Supplement, Mandatory Offer of

Medical Payments Coverage and Uninsured Motorists Coverage

62 NV 2001/05 Nevada Umbrella Supplement 80 NV 2022/01 Nevada Homeowner Application 83 NV 2022/01 Nevada Personal Umbrella Application 84 NV 2022/01 Nevada Dwelling Fire Application 85 NV 2022/01 Nevada Mobile Home Application 89 NV 2022/01 Nevada Residential Section 90 NV 2015/12 Nevada Personal Auto Application 137 NV 2015/12 Nevada Commercial Auto 138 NV 2015/12 Nevada Garage and Dealers 283 NV 2022/01 Nevada Personal Umbrella Application Section 290 NV 2014/12 Nevada Personal Auto Application Section

New Hampshire 90 NH 2021/07 New Hampshire Personal Auto Application 137 NH 2018/05 New Hampshire Commercial Auto 138 NH 2015/12 New Hampshire Garage and Dealers

290 NH 2021/07 New Hampshire Personal Auto Application Section

New Jersey 50 NJ 2016/12 State of NJ Temporary Evidence of Insurance 51 NJ 2016/12 State of NJ Insurance Identification Card

60 NJ 2001/10 New Jersey Homeowners Insurance Supplement Flood Exclusion

61 NJ 2016/09 New Jersey Auto Insurance Buyer’s Guide

62 NJ 2018/05 New Jersey Auto Supplement – Basic Policy

Coverage

64 NJ 2018/05 New Jersey Auto Supplement – Standard Policy

Coverage

65 NJ 2017/04 New Jersey Property Insurance Supplement – Earthquake

66 NJ 2016/09 New Jersey Auto Insurance Buyer’s Guide

Commercial PPA Edition

67 NJ 2018/06 NJUIA Dwelling Fire Application 68 NJ 2018/06 NJUIA Commercial Fire Application 90 NJ 2015/12 New Jersey Personal Auto Application 94 NJ 2006/04 Insurance Inspection Report

124 NJ 2021/11 New Jersey Supplement One-Page Summary -

Commercial Property/ Business Income Business Interruption Coverage

132 NJ 2015/09 New Jersey Workers Compensation Insurance

Plan Notes and Instructions (Coverage Request Form)

133 NJ 2015/09 New Jersey Workers Compensation Insurance Plan Coverage Request Form


Plan Notice of Election – Proprietors and Partners


Plan Employee Leasing Supplemental Request Form


Plan Truckers Supplemental Request Form

137 NJ 2015/12 New Jersey Commercial Auto 138 NJ 2015/12 New Jersey Garage and Dealers


Plan – NJ Workers compensation and Employers Liability Manual Part 3, Section 14

290 NJ 2015/12 New Jersey Personal Auto Application Section




1/29/2019

# Current Future Title Quantity New Mexico

60 NM 2003/01 New Mexico Confidential Abuse Disclosure

61 NM 2010/12 New Mexico Auto Supplement – UM Coverage

Selection / Rejection and Rejection of Stacked UM Coverage

90 NM 2015/12 New Mexico Personal Auto Application 137 NM 2015/12 New Mexico Commercial Auto 138 NM 2015/12 New Mexico Garage and Dealers

171 NM 2004/10 New Mexico Executive Employee Affirmative

Election Form

172 NM 2004/10 New Mexico Election to Accept 173 NM 2004/10 New Mexico Revocation

174 NM 2004/10 New Mexico Limited Liability Company Member Affirmative Election Form

290 NM 2014/12 New Mexico Personal Auto Application Section New York

38 NY 2005/04 New York Personal Insurance Supplement – Notice

of Information Practices

39 NY 2011/03 New York Insurance Supplement 60 NY 2008/03 New York Homeowners Supplement

61 NY 3/94 New York Auto Supplement (Optional Basic Econ.

Loss)

62 NY 2009/04 New York Application for Dwelling Insurance –

NYPIUA

64 NY 2018/06 New York Auto Supplement – Supp. UM/UIM Insurance Coverage

65 NY 2003/01 New York Auto Supplement – Spousal Liability

Coverage

66 NY 2012/01 New York Auto Supplement – Rental Reimbursement Notice

67 NY 2009/04 Instructions for Completion of ACORD 62 NY

68 NY 2002/01 New York Liability Supplement – “Claims-Made Policy”

69 NY 2008/08 New York Personal Property Supplement –

Important Flood Insurance Notice

70 NY 2006/04 NYPIUA Instructions for Completing ACORD 177 NY 80 NY 2022/02 New York Homeowner Application 83 NY 2022/02 New York Personal Umbrella Application 84 NY 2022/02 New York Dwelling Fire Application 85 NY 2022/02 New York Mobile Home Application 88 NY 2022/02 New York Personal Insurance Application 89 NY 2022/02 New York Residential Section 90 NY 2015/12 New York Personal Auto Application 137 NY 2015/12 New York Commercial Auto 138 NY 2015/12 New York Garage and Dealers 171 NY 10/96 New York Notice of Election of a Corporation

172 NY 7/96 New York Election of Partners or Self-Employed

Persons for Workers’ Compensation Coverage

173 NY 7/96 New York Election of Executive Officers of an

Organization for Workers’ Compensation Coverage

174 NY 7/96 New York Revocation of Executive officers of an

Organization for Workers’ Compensation Coverage

177 NY 2006/04 NYPIUA Application for Commercial Insurance 283 NY 2022/02 New York Personal Umbrella Section 290 NY 2015/12 New York Personal Auto Application Section

855 NY 2014/05 New York Construction Certificate of Liability Insurance Addendum

# Current Future Title Quantity North Carolina

64 NC 2008/04 North Carolina Property Supplement – Prop. Ins.

Notice Disclosure

65 NC 2010/02 North Carolina Auto Supplement – Notice of Right

to Purchase Higher Limits of Uninsured Motorist (UM) and Underinsured Motorist (UIM) Coverage

66 NC 8/97 North Carolina Insurance Supplement – Consent to Obtain Credit or Consumer Investigative Report

67 NC 2012/03 North Carolina Insurance Supplement – Policy

Service Fee Schedule

90 NC 2016/05 North Carolina Personal Auto Application

135 NC 2020/11 North Carolina Workers Comp. Insurance Plan –

Application

136 NC 2019/03 NCWCIP, Instructions for Completing ACORD 135 NC App.

137 NC 2015/12 North Carolina Commercial Auto 138 NC 2015/12 North Carolina Garage and Dealers

290 NC 2016/05 North Carolina Personal Automobile Application

Section

North Dakota

38 ND 2005/08 North Dakota Personal Insurance Supplement –

Notice of Information Practices

50 ND 2007/08 North Dakota Insurance Identification Card 62 ND 2015/04 North Dakota Insurance Supplement

68 ND 2004/07 North Dakota Supplement to Property Insurance –

Fire District

90 ND 2015/12 North Dakota Personal Auto Application 137 ND 2015/12 North Dakota Commercial Auto 138 ND 2015/12 North Dakota Garage and Dealers 290 ND 2014/12 North Dakota Personal Auto Application Section

Ohio

62 OH 2011/05 Ohio Auto Supplement – Important Optional

Disclosure Notice Uninsured Motorist Property Damage Coverage

67 OH 2009/07 Ohio Mine Subsidence Homeowners and Dwelling Supplement

68 OH 2009/07 Ohio Offer of Mine Subsidence – Homeowner and

Dwellings

90 OH 2015/12 Ohio Personal Auto Application 137 OH 2015/12 Ohio Commercial Auto 138 OH 2015/12 Ohio Garage and Dealers

170 OH 2002/09 Ohio FAIR Plan – Instructions for Completion of Insurance Apps.

171 OH 2004/03 Ohio FAIR Plan – Basic Property Application 172 OH 2002/09 Ohio FAIR Plan – Homeowners Supplement 173 OH 2002/09 Ohio FAIR Plan – Dwelling Fire Supplement 174 OH 2002/09 Ohio FAIR Plan – Commercial Supplement 175 OH 2002/09 Ohio FAIR Plan – Farm Supplement 176 OH 2002/09 Ohio FAIR Plan – Rehabilitation Supplement 177 OH 2002/09 Ohio FAIR Plan – Bowling Alley Supplement 290 OH 2014/12 Ohio Personal Automobile Application Section

Oklahoma 50 OK 2009/08 Oklahoma Owners Security Verification Form 51 OK 2009/08 Oklahoma Operators Security Verification form 60 OK 2009/11 Oklahoma Auto Supplement – UM Coverage Law

62 OK 2006/05 Oklahoma Property Supplement

Notice to Property Owners in Rural Fire Protection Districts

64 OK 2007/10 Oklahoma Liability Supplement 90 OK 2015/12 Oklahoma Personal Auto Application 137 OK 2015/12 Oklahoma Commercial Auto 138 OK 2015/12 Oklahoma Garage and Dealers 290 OK 2014/12 Oklahoma Personal Automobile Application Section

Oregon 38 OR 2013/01 Oregon Notice of Information Practices (Privacy) 61 OR 2016/01 Oregon Auto Supplement – UM Coverage Selection 62 OR 2006/01 Oregon Personal Lines Supplement 90 OR 2018/08 Oregon Personal Auto Application 137 OR 2016/01 Oregon Commercial Auto 138 OR 2016/01 Oregon Garage and Dealers 290 OR 2018/08 Oregon Personal Auto Application Section




# Current Future Title Quantity Pennsylvania

50 PA 2007/09 Pennsylvania Financial Responsibility Card

58 PA 2021/05 Pennsylvania Notice of Cancellation or Notice of

Nonrenewal

60 PA 2012/10 Pennsylvania UM Coverage Select/Reject

61 PA 2014/02 Pennsylvania Auto Supplement – Important

Notice

62 PA 2012/10 Pennsylvania UIM Coverage Select/Reject

64 PA 2015/05 Insurance Placement Facility of Pennsylvania

Basic Property Insurance Application

65 PA / DE/ WV

2015/05


66 PA 2015/05 Insurance Placement Facility of Pennsylvania

Dwelling Property 2 – Broad Form Application Supplement

90 PA 2015/12 Pennsylvania Personal Auto Application 137 PA 2015/12 Pennsylvania Commercial Auto 138 PA 2015/12 Pennsylvania Garage and Dealers

171 PA 2002/02 Pennsylvania Application for Executive Officer Exception

172 PA 2002/02 Pennsylvania Executive Officers Declaration 290 PA 2015/12 Pennsylvania Personal Auto Application Section

Puerto Rico 90 PR 2015/12 Puerto Rico Personal Auto Application 290 PR 2014/12 Puerto Rico Personal Auto Application Section

Rhode Island 50 RI 2008/01 Rhode Island Insurance Identification Card

61 RI 2012/12 Rhode Island Auto Supplement, Uninsured / Underinsured Motorist Bodily Injury Coverage

62 RI 2006/01 Rhode Island Prop. Suppl. – Notice of Flood

Coverage Exclusion

64 RI 2018/01 Rhode Island Joint Reinsurance Association,

Application for Homeowners Insurance Inspection and Placement

65 RI 2003/04 Rhode Island Joint Reinsurance Association,

Instructions for Completing Homeowners Applications ACORD 64 RI

66 RI 2012/12 Rhode Island Joint Underwriting Insurance

Application for Dwelling Fire and Personal Liability Insurance Inspection and Placement

67 RI 2007/03

Rhode Island Joint Underwriting Insurance Inspection Notice, Credit Reporting Notice and Instructions for Completing Dwelling Fire and Personal Liability Application ACORD 66 RI

68 RI 2017/12 Rhode Island Joint Underwriting Insurance

Application for Commercial Fire Insurance Inspection and Placement

69 RI 2003/04

Rhode Island Joint Underwriting Insurance Inspection Notice, Credit Reporting Notice and Instructions for Completing Commercial Fire Application ACORD 68 RI

90 RI 2015/12 Rhode Island Personal Auto Application 137 RI 2015/12 Rhode Island Commercial Auto 138 RI 2015/12 Rhode Island Garage and Dealers

290 RI 2016/06 Rhode Island Personal Automobile Application

Section

# Current Future Title Quantity South Carolina

9 SC 2019/07

South Carolina Required Notice for Motor Vehicle Insurance Applications

10 SC 2019/07 South Carolina Required Notice for Property and Casualty Applications

50 SC 2007/01 South Carolina Insurance Identification Card 60 SC 2019/09 South Carolina Auto Supplement, Required Notice

61 SC 2021/9 South Carolina Auto Supplement – Offer of Opt

UM/UIM Coverage

64 SC 2008/03 South Carolina Personal Property Supplement – Cancellation Rules Disclosure

65 SC 2021/9

South Carolina Auto Supplement - Offer Of Additional Uninsured Motorist Coverage And Optional Underinsured Motorist Coverage For Commercial/Business

90 SC 2020/04 South Carolina Personal Auto Application 137 SC 2015/12 South Carolina Commercial Auto 138 SC 2020/08 South Carolina Garage and Dealers

290 SC 2020/04 South Carolina Personal Automobile Application

Section

South Dakota 50 SD 2007/02 South Dakota Insurance Identification Card 61 SD 2013/02 South Dakota Personal Umbrella Supplement

62 SD 2019/10 South Dakota Auto Supplement: Required Notice

for Personal Umbrella Policies Without UM/UIM

90 SD 2015/12 South Dakota Personal Auto Application 137 SD 2015/12 South Dakota Commercial Auto 138 SD 2015/12 South Dakota Garage and Dealers 180 SD 2016/03 South Dakota Technology E&O Section 290 SD 2014/12 South Dakota Personal Auto Application Section

Tennessee 50 TN 2007/02 Tennessee Insurance Identification Card 90 TN 2015/12 Tennessee Personal Auto Application 137 TN 2021/11 Tennessee Commercial Auto 138 TN 2021/11 Tennessee Garage and Dealers 290 TN 2014/12 Tennessee Personal Automobile Application

Texas 50 TX 2020/1 Texas Liability Insurance Card 60 TX 2021/11 Texas Consumer Bill of Rights for Personal Auto

62 TX 2021/11 Texas Consumer Bill of Rights for Personal Auto

(Spanish)

64 TX 2003/04 Texas Windstorm Insurance Association

Application

67 TX 2021/11 Texas Homeowners and Personal Property –

Rights

68 TX 2021/11 Texas Homeowners and Personal Property –

Rights (Spanish)

69 TX 2000/08 Texas Special Mobile Home Windstorm/Hail

Application

90 TX 2015/12 Texas Personal Auto Application 137 TX 2015/12 Texas Commercial Auto 138 TX 2015/12 Texas Garage and Dealers 290 TX 2015/12 Texas Personal Automobile Application Section

851 TX 2020/07 TX Personal Lines Supp. – Use of Credit

Information Disclosure

852 TX 2020/07 TX Personal Lines Supp. (Spanish Version) – Use of

Credit Information Disclosure

854 TX 2012/08 Texas Risk Pool Certificate of Property Coverage 855 TX 2015/02 Texas Risk Pool Certificate of Liability Coverage




# Current Future Title Quantity United States

60 US 2020/09 Insurance Supplement – Offer of Terrorism

Coverage


Coverage Standard Fire Policy


Coverage Workers Compensation

Utah 51 UT 2014/07 Utah Insurance Identification Card

61 UT 2013/04 Utah Auto Supplement

Uninsured / Underinsured Motorist Coverage Selection

63 UT 9/93 Utah Fraud Statement 66 UT 6/94 Utah Arbitration Provisions

67 UT 2020/06 Utah Auto Supplement

PIP Coverage, Loss of Income Waiver

90 UT 2015/12 Utah Personal Auto Application 137 UT 2015/12 Utah Commercial Auto 138 UT 2015/12 Utah Garage and Dealers 290 UT 2014/12 Utah Personal Auto Application Section

Vermont 50 VT 2007/02 Vermont Automobile Insurance Identification Card

66 VT 2003/06 Vermont Insurance Supplement – Fair Credit

Reporting Act

90 VT 2020/08 Vermont Personal Auto Application 137 VT 2015/12 Vermont Commercial Auto 138 VT 2015/12 Vermont Garage and Dealers 290 VT 2020/08 Vermont Personal Auto Application Section

Virgin Islands 90 VI 2015/12 Virgin Islands Personal Auto Application 137 VI 2014/08 Virgin Islands Commercial Auto 138 VI 2015/06 Virgin Islands Garage and Dealers 290 VI 2014/12 Virgin Islands Personal Auto Application Section

Virginia 38 VA 2018/12 Virginia Notice of Information Practices (Privacy)

60 VA 2019/05 Virginia Auto Supplement – Rental Reimbursement Coverage

62 VA 6/97 Virginia Property Supplement

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 90 VA 2018/12 Virginia Personal Auto Application 137 VA 2019/05 Virginia Commercial Auto 138 VA 2015/12 Virginia Garage and Dealers 290 VA 2019/10 Virginia Personal Auto Application Section

Washington 90 WA 2016/12 Washington Personal Auto Application 137 WA

2016/12 Washington Commercial Auto

138 WA 2016/12

Washington Garage and Dealers

290 WA

2016/12 Washington Personal Auto Application Section

# Current Future Title Quantity West Virginia

38 WV 2020/9 West Virginia Personal Insurance Supplement

Notice of Insurance Information Practices

50 WV 2014/01 West Virginia Certificate of Insurance

60 WV 2021/06 West Virginia Auto Supplement – UM / UIM

Vehicle Coverage

61 WV 2016/01 West Virginia Auto Supplement – UM / UIM Coverage Offer Split Limits

62 WV 2016/01 West Virginia Auto Supplement – UM / UIM

Coverage Offer Single Limits

64 WV 2015/05 West Virginia Essential Property Insurance Association Basic Property Insurance Application

65 WV 2016/01 West Virginia Umbrella Liability Supplement

Important Notice

65 PA / DE / WV

2015/05


66 WV 2021/06 West Virginia Personal and Commercial Umbrella

Liability Supplement – UM / UIM Coverage – Offer of Split Limits


68 WV 2021/06

West Virginia Umbrella Liability Supplement UM / UIM Coverage – Offer of Single Limits

90 WV 2020/09 West Virginia Personal Auto Application 137 WV 2015/12

West Virginia Commercial Auto

138 WV

2015/12 West Virginia Garage and Dealers

290 WV 2020/09

West Virginia Personal Auto Application Section

862 WV

2005/07 West Virginia Property Supplement – Notice of Flood Coverage Exclusion

Wisconsin

4 WI 2003/04 Wisconsin Employers First Report of Injury or Disease

90 WI 2015/12 Wisconsin Personal Auto Application

97 WI 2003/10 Wisconsin Automobile Insurance Plan Private Passenger Auto Application

133 WI 2010/04 Wisconsin Workers Compensation Insurance Pool 134 WI 8/99 Wisconsin Supplementary Non-Election Form

135 WI 8/99 Wisconsin Supplementary Election of Coverage

Form

136 WI 2010/04 Wisconsin Supplement Limited Other States Coverage Request

137 WI 2015/12 Wisconsin Commercial Auto 138 WI 2015/12 Wisconsin Garage and Dealers

177 WI 2011/11 Wisconsin Automobile Insurance Plan Business

Auto Application

178 WI 2011/11 Wisconsin Automobile Insurance Plan – Truckers Application

290 WI 2016/06 Wisconsin Personal Auto Application Wyoming

90 WY 2015/12 Wyoming Personal Auto Application 137 WY 2015/12

Wyoming Commercial Auto

138 WY

2015/12 Wyoming Garage and Dealers

290 WY

2014/12

Wyoming Personal Auto Application Section

ACORD Forms Index ACORD Australia Forms – Available ONLY on the ACORD Web Site

AUSTRALIA FORMS

ACORD Member Services – Phone: (845) 620-1700 ACORD Forms Index (rev. 12/7/2021) All forms are available for download on the ACORD web site (http://www.acord.org) of 13

Number Edition Title 3020 2012/02 Home Certificate of Currency 3021 2012/02 Private Motor Certificate of Currency 3022 2012/02 Professional Indemnity Certificate of Currency 3023 2012/02 Commercial Motor Certificate of Currency 3045 2012/02 Interested Party Schedule 3080 2012/03 Home Application for Insurance 3090 2012/03 Personal Motor Application for Insurance 3098 2012/03 Personal Motor Vehicle Schedule 3101 2012/02 Additional Remarks Schedule 3129 2012/02 Commercial Motor Vehicle Schedule 3137 2012/02 Commercial Motor Application for Insurance 3163 2012/02 Commercial Driver Schedule 3823 2012/02 Additional Situations Schedule 3825 2012/02 Professional Indemnity Insurance Application 3826 2012/02 Industrial Special Risks Insurance Application 3827 2012/10 Business Package Application for Insurance

Number Edition Title

ACORD Forms Index ACORD Life/Annuity/Health Forms – Available ONLY on the ACORD Web Site

COUNTRYWIDE LIFE FORMS


Number Edition Title 650 2013/01 Authorization for the Release of Health Information

651 2007/07 Electronic Funds Transfer Authorization Form for Long Term Care Insurance

652 2007/07 Credit Card Payment Authorization Form for Long Term Care

Insurance 653 2008/04 Policy Delivery Receipt 660 2021/06 Insurance Agent (Producer) Disclosure for Annuities 731 2010/05 Request for Proposal – Additional Unions Schedule 661 2020/12 Consumer Refusal to Provide Information for Annuity Disclosures 732 2010/05 Request for Proposal – Additional Locations Schedule 733 2010/05 Request for Proposal – Additional Covered Affiliates Schedule 752 2004/01 Illustration Certification and Acknowledgement

759 2015/12 Important Notice Regarding Replacement – Model Regulation States

760 2007/03 Important Notice Regarding Replacement 764 2004/03 Fair Credit Reporting Act Disclosure 765 2004/01 Agent’s Report 766 2007/03 Life Product Comparison Form 771 2005/10 Laboratory Identification Form 781 2008/01 Informal Inquiry Application – Part 2 Medical History 782 2008/01 Medical Examiner’s Report 783 2008/01 HIV Antibody/Antigen Consent and Testing Form

784 2008/01 Informal Inquiry Application – Part 2 Medical History Medical Conditions Details / Additional Care Providers

785 2016/07 Request for Proposal – Employee Benefits 786 2016/07 Request for Proposal – Life Supplement 787 2016/07 Request for Proposal – Short Term Disability Supplement 788 2016/07 Request for Proposal – Long Term Disability Supplement 789 2010/05 Age Banded Rate Supplement 790 2010/05 Reducing Benefit Duration Schedule 791 2010/05 Administrative Services and Fee Schedule – Long Term Disability 792 2010/05 Administrative Services and Fee Schedule – Short Term Disability

Number Edition Title 794 2012/01 Request for Proposal – Dental and Vision Supplement 821 2015/10 Producer Information Form (PIF) 876 2015/10 Background Check Authorization

877 2015/10 Disclosure of Intent to Obtain Consumer Report or Investigate Consumer Report (except California)

951 2020/07 1035 Exchange / Rollover/ Transfer Form 951e 2017/06 1035 Exchange / Rollover / Transfer eForm

ACORD Forms Index ACORD Life/Annuity/Health Forms – Available ONLY on the ACORD Web Site

STATE LIFE FORMS


Number Edition Title Arkansas

966 AR 2007/03 Arkansas Annuity Product Comparison Form California

757 CA 2004/07 California HIV Antibody/Antigen Consent and Testing Form 760 CA 2015/06 California Notice Regarding Replacement

877 CA 2015/10 California Disclosure of Intent to Obtain an Investigative Consumer

Report 966 CA 2007/03 California Annuity Product Comparison Form

District of Columbia

757 DC 2004/07 District of Columbia HIV Antibody/Antigen Consent and Testing Form

Florida 757 FL 2005/03 Florida HIV Antibody/Antigen Consent and Testing Form

759 FL 2005/06 Florida Notice to Applicant Regarding Replacement of Life

Insurance 761 FL 2016/07 Florida Surrender of an Annuity or Life Insurance Policy 966 FL 2007/03 Florida Annuity Product Comparison Form

969 FL 2007/03 Florida Annuity Product Comparison Form Supplement – Policy /

Rider Description Delaware

760 DE 2017/01 Delaware Notice Regarding Replacement Georgia

760 GA 2017/01 Georgia Notice Regarding Replacement Idaho

760 ID 2017/01 Idaho Notice Regarding Replacement 960 ID 2020/10 Idaho Annuity Disclosure

Illinois 760 IL 2017/06 Illinois Notice Regarding Replacement

Indiana 760 A IN 2018/01 Indiana Notice Regarding Replacement 760 B IN 2018/01 Indiana Notice Regarding Replacement With Direct Response Sale

Massachusetts 757 MA 2004/11 Massachusetts HIV Antibody/Antigen Consent and Testing Form 760 MA 2015/06 Massachusetts Important Notice Regarding Replacement

Michigan 757 MI 2004/12 Michigan HIV Antibody/Antigen Consent and Testing Form

Number Edition Title Michigan

757 MI 2004/12 Michigan HIV Antibody/Antigen Consent and Testing Form Minnesota

760 MN 2015/12 Minnesota Notice Regarding Replacement New York

751 NY 2005/11 New York Authorization to Obtain and Disclose Information 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

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

Only Ohio

757 OH 2009/02 Ohio HIV Antibody/Antigen Consent and Testing Form Oregon

757 OR 2004/07 Oregon HIV Antibody/Antigen Consent and Testing Form Rhode Island

761RI 2019/01 Rhode Island Notice to Inform Policyholders of Alternatives 766 RI 2007/03 Rhode Island Life Product Comparison Form

Texas 757 TX 2004/11 Texas HIV Antibody/Antigen Consent and Testing Form

Virginia 655 VA 2010/12 Virginia Group Health Insurance – Medical History Form

Washington 757 WA 2010/05 Washington HIV Antibody/Antigen Consent and Testing Form 760 WA 2015/06 Washington Important Notice Regarding Replacement

forms index october r2 - acord.org

Documents