All packages contain 100 forms - Please specify number of packages required ACORD Forms Index Page 2 of 12 Hotel / Motel Supplement 2015/12 Premium Payment Supplement
ACORD Forms Index Please provide the information below to avoid delay in shipment. Agency/Company Name:
Contact Name:
Street Address: City:
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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 #
Current
Future
Title
Quantity
#
Current
Future
Title
Quantity
1
2013/01
Property Loss Notice
70
2015/09
Personal Policy Change Request (Except Auto)
2
2013/01
Automobile Loss Notice
71
2015/09
Personal Auto Policy Change Request
3
2013/01
General Liability Notice of Occur/Claim
72
2009/10
Mobile Home Supplement
4
2013/01
Workers Compensation - First Report of Injury or Illness
73
2009/07
Solid Fuel Questionnaire - Supplement to Residential Section
5
2013/01
Aircraft Loss Notice
74
2009/09
6
2009/05
Aviation Witness / Passenger Schedule
Residence Based Business Supplement to Residential Section
75
2016/03
Insurance Binder
7
2009/05
Aviation Injured Schedule 76
9/93
Binder Log
80
2016/03
Homeowner Application
81
2016/03
Personal Inland Marine Application
82
2016/03
Watercraft Application
83
2016/04
Personal Umbrella Application
84
2016/03
Dwelling Fire Application
85
2016/03
Mobile Home Application
11 12 13 20 21 22
2/95 2/95 2/95 2016/03 2016/03 2016/03
Auto Accident Information Form Exchange of Information Form Witness Card Certificate of Aviation Liability Insurance Certificate of Aircraft Insurance Intermodal Interchange Certificate of Insurance
23
2016/03
Vehicle or Equipment Certificate of Insurance
24
2016/03
Certificate of Property Insurance
88
2015/12
Personal Insurance Application - Applicant Information Section
25
2016/03
Certificate of Liability Insurance
89
2016/03
Residential Section
26
2002/01
Policy Certification Log
91
2009/10
Good Student Driver Training
27
2016/03
Evidence of Property Insurance
92
2012/03
Medical Statement
28
2016/03
Evidence of Commercial Property Insurance
93
2012/03
Young Driver Questionnaire
29
2016/03
Evidence of Flood Insurance
99
2009/02
Accidents / Convictions Schedule
30
2016/03
Certificate of Garage Insurance
101
2008/01
Additional Remarks Schedule
31
2016/03
Certificate of Marine / Energy Insurance
103
2012/03
35
2016/03
Cancellation Request / Policy Release
Personal Auto Application Schedule - Additional Resident and Driver Information Section
105
2012/06
Apartment Building Supplement
36
2007/01
Agent/Broker of Record Change 106
2010/04
Vacant Building Supplement Commercial Insurance Application Applicant Information Section
37
2008/01
Statement of No Loss
38
2013/01
Notice of Insurance Information Practices (Privacy)
125
2016/03
42
2014/08
Residential Property Replacement Cost
126
2016/03
45
2016/03
Additional Interest Schedule
127
2015/12
Business Auto Section
50
2007/02
Automobile Insurance ID Card
128
2015/12
Garage and Dealers Section
50 WM
2007/03
Automobile Insurance ID Card (with Watermark)
129
2009/11
Vehicle Schedule
54
1/97
Financial Responsibility Form
130
2013/09
Workers Compensation Application
57
1/97
Financial Responsibility Form - Cancellation
131
2016/04
Umbrella Section
58
2007/11
Notice of Cancellation or Termination of Policy
132
2015/12
Truckers / Motor Carriers Section
60
2010/04
Flood Insurance Selection / Rejection
133
2016/03
60 US
2015/01
Insurance Supplement - Notice - Offer of Terrorism Coverage
Workers Compensation Insurance Plan - Assigned Risk Section
2015/12
Statement / Schedule of Values
2015/01
Insurance Supplement - Standard Fire Policy Only Notice - Offer of Terrorism Coverage
139
62 US
140
2016/03
Property Section
63
2016/04
Fraud Statements
141
2016/03
Crime Section
2015/01
Insurance Supplement - Workers' Compensation Only Notice - Offer of Terrorism Coverage
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
64 US 66
2011/05
Personal Insurance Supplement - Extraordinary Life Circumstances
68
2016/06
Electronic Delivery Supplement
2016/09
Commercial General Liability Section
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 1 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required COUNTRYWIDE P&C FORMS - continued #
Current
#
Current
148
2016/03
Electronic Data Processing Section
340
2016/03
Aircraft Change Request
149
2013/09
Dealers Section
341
2011/11
Pilot Experience Change Request
152
2015/06
Commercial Inland Marine Section
342
2009/06
Hangar Change Request
Boiler & Machinery 2002 / Equipment Breakdown Section
350
Watermark Paper - 20 # ID Card Stock (4-part perforation)
Schedule of Insurance
360
Watermark Paper - 32 # ID Card Stock (4-part perforation)
Business Owners Section
370
155 BM 2014/12
Future
2016/09
Title
Quantity
Future
Title
Quantity
159
2014/09
160
2015/06
163
2012/06
Commercial Auto Driver Information Schedule
401
2016/03
Agriculture Application
175
2016/03
Commercial Policy Change Request
402
2016/03
Agriculture Property Section
180
2016/03
Technology E&O Section - Electronic Data Processors, Electronic Products Manufacturers, Computer Services etc.
403
2016/03
Agriculture Property Section Scheduled / Unscheduled Personal Property
185
2011/09
Restaurant / Tavern Supplement
404
2016/03
Agriculture Liability Section
186
2011/10
Contractors Supplement
405
2007/09
Agriculture Premises Diagram
187
2016/03
Professional Liability Supplement
406
2007/09
190
2013/09
Supplemental Property Application
Agriculture Supplement - Unscheduled Farm Personal Property Inventory Form
407
2016/03
Livestock Mortality Section
193
2013/09
Open Cargo Section 408
2007/09
Equine Liability Supplement
410
2016/03
Small Farm / Ranch Application
501
2016/06
Surety Report of Execution
502
2015/04
Contract Bond Request Form
503
2016/06
Commercial and 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
2014/12
Business Income / Extra Expense / Rental Value Supplement to Property Section
194 195 196 199 200 201 210
2009/03
226 275 276 281
Design Professional's Individual Property Survey
2013/09
Medical Professional Liability Insurance Application
1/99
Application Supplement - Undertaking
3/93
Producer Account
3/93
Producer Account Discrepancy Notice
2016/03
Yacht Section 2016/09
1/98 3/93 2016/03 2016/03 2016/05
Watermark Paper - 32 # ID Card Stock (non-perforated)
Truckers / Motor Carrier Supplement
10/96
211 225
2016/09
Schedule of Hazards Policyholder's Report Statement of Premium Adjustment Aviation Insurance Binder Aircraft Insurance Binder Personal Inland Marine Section
282
2016/05
Watercraft Section
810
283
2016/04
Personal Umbrella Application Section
811
2014/12
Value Reporting Information Supplement to Property Section
2015/04
National Flood Insurance Program Flood Insurance Application
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
2013/01
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)
301 302 303 304 305
2015/04 2015/04 2015/04 2012/02
NFIP - Flood Insurance General Change Endorsement NFIP - Flood Insurance Preferred Risk Policy Application NFIP - Flood Insurance Cancellation / Nullification NFIP - Credit Card Payment Form
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
306
326 327 328 329 330 331 332 333
2006/04 2016/03 2014/12 2014/12 2016/03 2011/11 2006/04 2009/05
Airport Property Supplement Airport and FBO Liability Section Private Hangar Liability Section Aviation Products Liability Aircraft Section Pilot Experience Hangar Schedule 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
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 2 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS #
Current
Future
Title
Quantity
#
Current
Alabama
Future
Title
Quantity
California (continued)
50 AL
2007/10
Alabama Insurance Identification Card
137 CA
2015/12
California Commercial Auto
62 AL
5/98
Alabama Insurance Application Supplement
138 CA
2016/02
California Garage and Dealers
90 AL
2015/12
Alabama Personal Auto Application
177 CA
2015/09
California Auto Body Repair Consumer Bill of Rights
137 AL
2015/12
Alabama Commercial Auto
290 CA
2014/12
California Personal Auto Application Section
138 AL
2015/12
Alabama Garage and Dealers
854 CA
2015/01
290 AL
2014/12
Alabama Personal Automobile Application Section
California FAIR Plan Property Insurance - Application for Dwelling Insurance
855 CA
2016/01
California FAIR Plan Property Insurance - Application for Commercial Insurance
856 CA
2016/01
California FAIR Plan Property Insurance - Application for Businessowners (BOP) Insurance
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
857 CA
2011/02
California Earthquake Authority - Application for Earthquake Insurance
137 AK 2015/12
Alaska Commercial Auto
860 CA
2004/12
California Auto Supplement - Driver Self Certification
138 AK 2015/12
Alaska Garage and Dealers
861 CA
2011/07
California Residential Property Insurance Bill of Rights
171 AK 6/98
Alaska Petition For Executive Officer Waiver
877 CA
2015/10
290 AK
Alaska Personal Auto Application Section
California Disclosure of Intent to Obtain an Investigative Consumer Report
50 CO
2007/03
Colorado Insurance Identification Card
61 CO
2012/01
Colorado Auto Supplement - Summary of Coverages
2014/12
Arkansas
Colorado
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
64 CO
2009/01
Colorado Auto Supplement - Colorado Offer of Medical Payments Coverage
67 AR
2000/02
Arkansas Property Supplement - Declination of Residential Earthquake Coverage
65 CO
2013/02
Colorado Personal Property Supplement - Summary of Coverage Renters Policy
66 CO
2013/02
Colorado Personal Property Supplement - Summary of Coverage Condominium Policy
90 AR
2015/12
Arkansas Personal Auto Application
137 AR
2015/12
Arkansas Commercial Auto
138 AR
2015/12
Arkansas Garage and Dealers
67 CO
2013/02
Colorado Personal Property Supplement - Summary of Coverage Dwelling Fire Policy
180 AR
2016/03
Arkansas Technolgy E&O Section
68 CO
2013/02
290 AR
2014/12
Arkansas Personal Auto Application Section
Colorado Personal Property Supplement - Summary of Coverage Homeowners Policy
807 AR
2016/03
Arkansas Directors & Officers Liability Section
69 CO
2014/01
Colorado Personal Property Supplement - Homeowner's Insurance Replacement-Cost Policy Applicants
827 AR
2016/03
Arkansas Employment Practices Liability Insurance Section
90 CO
2015/12
Colorado Personal Automobile Application
828 AR
2016/03
Arkansas Fiduciary Liability Coverage Section
137 CO 2015/12
Colorado Commercial Auto
832 AR
2016/03
Arkansas Miscellaneous E&O Section
138 CO 2015/12
Colorado Garage and Dealers
833 AR
2014/12
Arkansas Lawyers Professional Liability Section
171 CO 2006/01
Colorado Rejection of Coverage by Corporate Officers
834 AR
2014/12
Arkansas Cyber and Privacy Coverage Section
290 CO 2014/12
Colorado Personal Automobile Application Section
838 AR
2013/12
Arkansas Accountants Professional Liability Section 50 CT
2009/01
Connecticut Insurance Identification Card
Arizona
Connecticut
38 AZ
2003/10
Arizona Notice of Information Practices (Privacy)
61 CT
2010/01
Connecticut Auto Supplement - UM Coverage
50 AZ
2012/08
Arizona Insurance Identification Card
62 CT
2011/07
61 AZ
2001/02
Arizona Auto Supplement UM/UIM Coverage Selection
Connecticut Personal Insurance Supplement - Summary of Consumer Protections
90 AZ
2015/12
Arizona Personal Auto Application
66 CT
2015/02
Connecticut FAIR Plan Application for Property / Liability Insurance
137 AZ
2015/12
Arizona Commercial Auto
90 CT
2015/12
Connecticut Personal Auto Application
138 AZ
2015/12
Arizona Garage and Dealers
137 CT
2015/12
Connecticut Commercial Auto
290 AZ
2014/12
Arizona Personal Automobile Application Section
138 CT
2015/12
Connecticut Garage and Dealers
171 CT
2006/08
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
2006/08
Connecticut Workers' Comp. Comm. - Coverage Election by Employees who are Members of a Partnership
173 CT
2006/08
Connecticut Workers' Comp. Comm. - Coverage Election by Sole Proprietor or Single-Member LLC
290 CT
2014/12
Connecticut Personal Automobile Application Section
California 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
2004/07
California Insurance Supplement - Race, National Origin, Gender
66 CA
2011/04
California Offer of Earthquake Coverage
67 CA
2011/07
California Residential Property Insurance Disclosure
68 CA
2001/03
California Scheduled Personal Property Loss Computation Disclosure
69 CA
2013/10
California Insurance Supplement
90 CA
2015/12
California Personal Auto Application
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 3 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS #
Current
Future
Title
Quantity
#
Current
Delaware 38 DE
2008/04
Future
Title
Quantity
Florida (continued)
Delaware Personal Insurance Supplement Notice of Information Practices (Privacy)
221 FL
2002/07
Citizens Property Ins Corp, Wind Only - Supplemental Application Schedule Commercial and Commercial Residential
61 DE
2006/10
DE Auto Supplement, DE Motorist's Protection Act Required Statement to Policyholders
283 FL
2014/12
Florida Personal Umbrella Application Section
62 DE
2004/10
DE Auto Supplement, PIP Deductible Options
860 FL
2011/11
Florida Commercial Auto Addendum
64 DE
2015/05
Insurance Placement Facility of Delaware Basic Property Insurance Application
862 FL
2013/12
Florida Personal Auto Supplement
863 FL
2013/12
Florida Personal Auto Supplement
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
65 PA / DE 2015/05 / WV
FAIR Plan Supplementary Questionnaire
67 DE
2012/01
Delaware Insurance Supplement
90 DE
2015/12
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
2015/12
Georgia
90 GA
2015/12
Georgia Personal Auto Application
137 GA
2015/12
Georgia Commercial Auto
138 GA
2015/12
Georgia Garage and Dealers
2013/05
Georgia State Board of Workers' Compensation - Notice of Election or Rejection of Workers' Compensation Coverage
2014/12
Georgia Personal Automobile Application Section
Delaware Personal Auto Application Section
District of Columbia 62 DC
2013/09
District of Columbia Personal Property Supplement, Statement Regarding Flood Insurance
171 GA
2013/10
Application to District of Columbia Property Insurance Facility for Basic Property Insurance
290 GA
64 DC 66 DC
2013/10
District of Columbia Property Insurance Facility - Essential Homeowners Ins. Inspection and Placement Application p. 1
67 DC
2013/10
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 Application Section
50 FL
2009/07
Florida Personal Auto ID Card
51 FL
2009/07
Florida Commercial 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
7/94
Florida Homeowners Supplement
70 FL
2012/02
Florida Property Supplement Uniform Mitigation Verification Inspection Form
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 Section
130 FL
2015/02
Florida Workers Compensation Application
133 FL
2013/03
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 Workers Compensation Monthly Change Sheet
220 FL
2012/12
Citizens Property Insurance Corporation Commercial - Residential Wind Only
Florida
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 4 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS - continued #
Current
Future
Title
Quantity
#
Current
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
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
Hawaii Vehicle Inspection Report Supplement
137 HI
2015/12
Hawaii Commercial Auto
138 HI
2015/12
Hawaii Garage and Dealers
171 KS 2005/11
Kansas Elec. of Individual, Partner or Self-Employed Individual
290 HI
2014/12
Hawaii Personal Auto Application Section
172 KS 2005/11
Kansas Cancel. of Elec. of Individual, Partner or Self-Employed Individual
173 KS 2005/11
Kansas Cancellation of Election Not to Accept Coverage
50 ID
2007/10
State of Idaho Liability Insurance Identification Card 174 KS 2005/11
Kansas Election Not to Accept Coverage
176 KS 2005/11
Kansas Election of Employer to Cover Employees
Idaho
61 ID
2009/01
Idaho Auto Supplement - Idaho Uninsured Motorist and Underinsured Motorist Disclosure Statement
90 ID
2015/12
Idaho Personal Auto Application
177 KS 2005/11
Kansas Election of Coverage for Volunteer Workers
137 ID
2015/12
Idaho Commercial Auto
178 KS
2005/11
138 ID
2015/12
Idaho Garage and Dealers
Kansas Cancellation of Election of Employer to Cover Employees
290 ID
2014/12
Idaho Personal Automobile Application Section
179 KS
2005/11
Kansas Cancel. of Election of Coverage for Volunteer Workers
180 KS
2005/11
50 IL
2007/03
Illinois Insurance Identification Card
61 IL
2015/01
Illinois Auto Supplement - UM/UIM
181 KS
2005/11
Kansas Cancellation of Election of Coverage for Persons Performing Public Service
62 IL
2007/08
Illinois Property Supplement - Notice of Availability of Earthquake Insurance
182 KS
2001/05
Kansas Election of a Noncompensated Volunteer to be Covered
67
2015/07
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement
183 KS
2001/05
Kansas Cancellation of Election of a Noncompensated Volunteer to be Covered
67 IL
2012/01
Illinois Insurance Supplement - Civil Union Disclosure
290 KS
2016/04
Kansas Personal Auto Application Section
90 IL
2015/12
Illinois Personal Auto Application
137 IL
2015/12
Illinois Commercial Auto
50 KY
2006/01
Commonwealth of Kentucky Proof of Insurance
138 IL
2015/12
Illinois Garage and Dealers
60 KY
2015/09
Kentucky Auto Supplement - Rejection of Uninsured / Underinsured Motorist Coverage
171 IL
2005/06
Illinois FAIR Plan Application for Commercial Property Insurance
64 KY
2011/01
Kentucky FAIR Plan Homeowners Application
290 IL
2014/12
Illinois Personal Auto Application Section
65 KY
2011/01
Kentucky FAIR Plan Dwelling Fire Application
66 KY
2011/01
Kentucky FAIR Plan Farm Fire Application
Illinois
Indiana
Kansas Election of Coverage for Persons Performing Public Service
Kentucky
2007/11
Indiana Insurance Identification Card
67
2015/07
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement
67
2015/07
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement
68 KY
2011/01
Kentucky FAIR Plan Commercial Fire Application
90 IN
2015/12
Indiana Personal Auto Application
90 KY
2015/09
Kentucky Personal Auto Application
137 IN
2015/12
Indiana Commercial Auto
137 KY
2015/09
Kentucky Commercial Auto
138 IN
2015/12
Indiana Garage and Dealers
138 KY
2015/09
Kentucky Garage and Dealers
290 IN
2014/12
Indiana Personal Auto Application Section
290 KY
2015/09
Kentucky Personal Auto Application Section
50 IN
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
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 5 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS - continued #
Current
Future
Title
Quantity
#
Current
Louisiana
Future
Title
Quantity
Massachusetts 60 MA
2012/07
Massachusetts Property Insurance Underwriting Association Application for Homeowners Insurance
61 MA
2003/04
Massachusetts Property Insurance Underwriting Association Instructions to Complete Homeowners Application ACORD 60 MA
Louisiana Homeowners Supplement Loss Settlement (HO2 & 3)
64 MA
2/97
Massachusetts Residential Property Liability Supplement Lead Poisoning Liability Disclosure Notice
2001/02
Louisiana Homeowners Supplement - Loss Settlement (HO6)
65 MA
2015/01
66 LA
4/98
Louisiana Dwelling Supplement - Loss Settlement DWG2 & 3
Massachusetts Property Insurance Underwriting Association Application for Dwelling Fire and Liability Insurance Inspection and Placement
67 LA
5/98
Louisiana Certification of Mobile Home Tie Downs
66 MA
2015/01
68 LA
4/98
Louisiana Plan Services Application for Insurance
Massachusetts Property Ins Underwriting Assn - Instructions for Completing Dwelling Fire and Liability Insurance Application ACORD 65 MA
90 LA
2015/12
Louisiana Personal Auto Application
67 MA
2003/04
Massachusetts Property Ins Underwriting Assn - Application for Commercial Fire Insurance Inspection and Placement
137 LA
2015/12
Louisiana Commercial Auto 68 MA
2003/04
138 LA
2015/12
Louisiana Garage and Dealers
Massachusetts Property Insurance Underwriting Association Inspection Notice, Credit Reporting Notice and Instructions for Completing Commercial Fire Application ACORD 67 MA
290 LA
2014/12
Louisiana Personal Auto Application Section
69 MA
2010/07
Massachusetts Residential Property Liquid Fuel Spill Supplement
861 LA
2005/07
Louisiana Auto Supplement - Active Military Personnel Affidavit
90 MA
2012/08
Application for Massachusetts Motor Vehicle Insurance
862 LA
2009/06
Louisiana Property Supplement - Hurricane Loss Mitigation Survey
95 MA
2009/12
Massachusetts Renewal Application (Statement of Facts)
50 LA
2008/03
Louisiana Auto ID 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
65 LA
Maine 50 ME
2007/08
Maine Motor Vehicle Insurance Identification Card
90 ME
2015/12
Maine Personal Auto Application
137 MA 2015/12
Massachusetts Commercial Auto
138 MA 2015/12
Massachusetts Garage and Dealers
50 MI
2010/08
State of Michigan Certificate of No-Fault Insurance
Michigan
137 ME 2015/12
Maine Commercial Auto
138 ME 2015/12
Maine Garage and Dealers
60 MI
2010/03
Michigan Automobile Insurance Placement Facility Michigan Auto Supplement - Declaration of Intent to Reside
290 ME 2015/12
Maine Personal Auto Application Section
62 MI
2014/03
Michigan Collision Insurance Options Notice
64 MI
2000/10
Michigan Basic Property Insurance Assn Insurance Application
90 MI
2015/12
Michigan Personal Auto Application
133 MI
2012/08
Michigan Application for Workers' Compensation Insurance
137 MI
2015/12
Michigan Commercial Auto
Maryland 39 MD
2016/05
Maryland Personal Insurance Supplement
62 MD
1/98
Maryland Commercial Auto Supplement
64 MD
2013/10
Maryland Property Insurance Availability Program Essential Property Insurance Inspection and Placement
65 MD
2013/10
Maryland Property Insurance Availability Program - Essential Homeowners Insurance Inspection and Placement (p. 1 of 2)
138 MI
2015/12
Michigan Garage and Dealers
66 MD
2013/10
Maryland Property Insurance Availability Program - Essential Homeowners Insurance Inspection and Placement (p. 2 of 2)
139 MI
2004/07
Michigan Automobile Insurance Placement Facility Supplement to ACORD App. - Application for Commercial, Public Automobiles and Corporately Owned Vehicles
2005/01
Michigan Notice of Election
2011/01
Maryland Personal Auto Supplement - Mandatory Offer of Increased Liability Coverage for Claims of Family Members, Mandatory PIP Waiver, and Mandatory UM Coverage Waiver
171 MI
67 MD
172 MI
4/96
Michigan Application for Exclusion of Partner(s), Spouse, Child or Parent
68 MD 69 MD 90 MD
2007/01
Maryland Personal Property Supplement - Statement Regarding Flood Insurance
2013/10
Maryland Insurance Supplement - Notice of Underwriting Period
2015/12
173 MI
2000/09
Michigan WC Placement Facility Specific Person Exclusion
290 MI
2014/12
Michigan Personal Automobile Application Section
860 MI
2010/03
Michigan Auto Supplement - Declaration of Intent to Reside
Maryland Personal Auto Application
137 MD 2015/12
Maryland Commercial Auto
138 MD 2015/12
Maryland Garage and Dealers
290 MD 2014/12
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
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 6 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS - continued #
Current
Future
Title
Quantity
#
Current
Minnesota
Future
Title
Quantity
Nebraska
38 MN
2013/01
Minnesota Authorization
50 NE
2007/01
Nebraska Auto Liability Insurance Identification Card
62 MN
2000/01
Minnesota Auto Supplement
90 NE
2015/12
Nebraska Personal Auto Application
65 MN
2012/04
Minnesota Insurance Guarantee Association Notice
137 NE 2015/12
Nebraska Commercial Auto
90 MN
2015/12
Minnesota Personal Auto Application
138 NE 2015/12
Nebraska Garage and Dealers
137 MN 2015/12
Minnesota Commercial Auto
290 NE 2014/12
Nebraska Personal Auto Application Section
138 MN 2015/12
Minnesota Garage and Dealers
290 MN 2015/12
Minnesota Personal Auto Application Section
51 NV
2016/01
Nevada Temporary Insurance Identification Card
807 MN 2016/03
Minnesota Directors & Officers Liability Section
52 NV
2016/01
Nevada Permanent Insurance Identification Card
827 MN 2016/03
Minnesota Employment Practices Liability Insurance Section
53 NV
2016/01
828 MN 2016/03
Minnesota Fiduciary Liability Coverage Section
Nevada Temporary Insurance Identification Card, Evidence of Operator's Policy of Liability Insurance
832 MN 2016/03
Minnesota Miscellaneous E&O Section
54 NV
2016/01
Nevada Permanent Insurance Identification Card, Evidence of Operator's Policy of Liability Insurance
833 MN 2014/12
Minnesota Lawyers Professional Liability Section
61 NV
2002/12
834 MN 2014/12
Minnesota Cyber and Privacy Coverage Section
Nevada Auto Supplement, Mandatory Offer of Medical Payments Coverage and Uninsured Motorists Coverage
62 NV
2001/05
Nevada Umbrella Supplement
838 MN 2013/12
Minnesota Accountants Professional Liability Section 90 NV
2015/12
Nevada Personal Auto Application
137 NV
2015/12
Nevada Commercial Auto
138 NV
2015/12
Nevada Garage and Dealers
290 NV
2014/12
Nevada Personal Auto Application Section
853 MN 2010/08
Minnesota Homeowners Personal Property Supplement
Mississippi 50 MS 61 MS
2008/01
90 MS
Mississippi Auto Insurance ID Card
2013/07
62 MS
Nevada
Mississippi Auto Supplement - Non-Stacking UM Insurance
New Hampshire
2016/07
Mississippi Auto Supplement - Selection / Rejection of Uninsured Motorist Insurance
90 NH
2015/12
New Hampshire Personal Auto Application
2015/12
2016/07
Mississippi Personal Auto Application
137 NH
2015/12
New Hampshire Commercial Auto
137 MS 2015/12
2016/07
Mississippi Commercial Auto
138 NH
2015/12
New Hampshire Garage and Dealers
138 MS 2015/12
2016/07
Mississippi Garage and Dealers
290 NH
2014/12
New Hampshire Personal Auto Application Section
50 NJ
2005/05
Temporary State of New Jersey Insurance Identification Card
139 MS 2/99 290 MS 2014/12
New Jersey
Mississippi Statement/Schedule of Values 2016/07
Mississippi Personal Auto Application Section
Missouri
51 NJ
2007/06
Permanent State of New Jersey Insurance Identification Card
2007/05
Missouri Auto Insurance ID Card
60 NJ
2001/10
New Jersey Homeowners Insurance Supplement Flood Exclusion
62 MO
2007/08
Missouri Property Supplement - Notice of Availability of Earthquake Insurance
61 NJ
2011/07
New Jersey Auto Insurance Buyer's Guide
67 MO
2009/06
Missouri FAIR Plan Insurance Application
62 NJ
2006/10
New Jersey Auto Supplement - Basic Policy Coverage
90 MO
2015/12
Missouri Personal Auto Application
64 NJ
2010/03
New Jersey Auto Supplement - Standard Policy Coverage
137 MO 2015/12
Missouri Commercial Auto
65 NJ
2003/02
New Jersey Property Insurance Supplement - Earthquake
138 MO 2015/12
Missouri Garage and Dealers
66 NJ
2011/07
290 MO 2014/12
Missouri Personal Auto Application Section
New Jersey Auto Insurance Buyer's Guide Commercial PPA Edition
67 NJ
2010/08
NJUIA Dwelling Fire Application
68 NJ
2010/05
NJUIA Commercial Fire Application
90 NJ
2015/12
New Jersey Personal Auto Application
94 NJ
2006/04
Insurance Inspection Report
50 MO
Montana 60 MT 90 MT
2003/09 2015/12
Montana Application Supplement - Refusal to Renew Montana Personal Auto Application
137 MT
2015/12
Montana Commercial Auto
138 MT
2015/12
Montana Garage and Dealers
132 NJ
2015/09
New Jersey Workers Compensation Insurance Plan Notes and Instructions (Coverage Request Form)
290 MT
2015/12
Montana Personal Auto Application Section
133 NJ
2015/09
807 MT
2016/03
Montana Directors & Officers Liability Section
New Jersey Workers Compensation Insurance Plan Coverage Request Form
827 MT
2016/03
Montana Employment Practices Liability Insurance Section
134 NJ
2015/09
New Jersey Workers Compensation Insurance Plan Notice of Election - Proprietors and Partners
828 MT
2016/03
Montana Fiduciary Liability Coverage Section
135 NJ
2015/09
832 MT
2016/03
Montana Miscellaneous E&O Section
New Jersey Workers Compensation Insurance Plan Employee Leasing Supplemental Request Form
833 MT
2014/12
Montana Lawyers Professional Liability Section
136 NJ
2015/09
New Jersey Workers Compensation Insurance Plan Truckers Supplemental Request Form
834 MT
2014/12
Montana Cyber and Privacy Coverage Section
137 NJ
2015/12
New Jersey Commercial Auto
838 MT
2013/12
Montana Accountants Professional Liability Section
138 NJ
2015/12
New Jersey Garage and Dealers
171 NJ
2003/07
New Jersey Workers Compensation Insurance Plan - NJ Workers Compensation and Employers Liability Manual Part 3, Section 14
290 NJ
2015/12
New Jersey Personal Auto Application Section
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 7 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS - continued #
Current
Future
Title
Quantity
#
Current
New Mexico
Future
Title
Quantity
North Dakota
2003/01
New Mexico Confidential Abuse Disclosure
38 ND
2005/08
North Dakota Personal Insurance Supplement - Notice of Information Practices
61 NM
2010/12
New Mexico Auto Supplement - UM Coverage Selection / Rejection and Rejection of Stacked UM Coverage
50 ND
2007/08
North Dakota Insurance Identification Card
90 NM
2015/12
New Mexico Personal Auto Application
62 ND
2015/04
North Dakota Insurance Supplement
137 NM 2015/12
New Mexico Commercial Auto
68 ND
2004/07
North Dakota Supplement to Property Insurance - Fire District
138 NM 2015/12
New Mexico Garage and Dealers
90 ND
2015/12
North Dakota Personal Auto Application
171 NM 2004/10
New Mexico Executive Employee Affirmative Election Form
137 ND
2015/12
North Dakota Commercial Auto
172 NM 2004/10
New Mexico Election to Accept
138 ND
2015/12
North Dakota Garage and Dealers
173 NM 2004/10
New Mexico Revocation
290 ND
2014/12
North Dakota Personal Auto Application Section
174 NM 2004/10
New Mexico Limited Liability Company Member Affirmative Election Form 62 OH
2011/05
Ohio Auto Supplement - Important Optional Disclosure Notice Uninsured Motorist Property Damage Coverage
60 NM
Ohio
290 NM 2014/12
New Mexico Personal Auto Application Section
67 OH
2009/07
Ohio Mine Subsidence Homeowners and Dwelling Supplement
38 NY
2005/04
New York Personal Insurance Supplement - Notice of Information Practices
68 OH
2009/07
Ohio Offer of Mine Subsidence - Homeowners and Dwelling
39 NY
2011/03
New York Insurance Supplement
90 OH
2015/12
Ohio Personal Auto Application
60 NY
2008/03
New York Homeowners Supplement
137 OH 2015/12
Ohio Commercial Auto
61 NY
3/94
New York Auto Supplement (Optional Basic Econ Loss)
138 OH 2015/12
Ohio Garage and Dealers
62 NY
2009/04
New York Application For Dwelling Insurance - NYPIUA
170 OH 2002/09
Ohio FAIR Plan - Instructions for Completion of Insurance Apps
64 NY
2008/06
New York Auto Supplement - Supp UM/UIM Insurance Coverage
171 OH 2004/03
Ohio FAIR Plan - Basic Property Application
65 NY
2003/01
New York Auto Supplement - Spousal Liability Coverage
172 OH 2002/09
Ohio FAIR Plan - Homeowners Supplement
66 NY
2012/01
New York Auto Supplement - Rental Reimbursement Notice
173 OH 2002/09
Ohio FAIR Plan - Dwelling Fire Supplement
67 NY
2009/04
Instructions for Completion of ACORD 62 NY
174 OH 2002/09
Ohio FAIR Plan - Commercial Supplement
68 NY
2002/01
New York Liability Supplement - "Claims-Made Policy"
175 OH 2002/09
Ohio FAIR Plan - Farm Supplement
69 NY
2008/08
New York Personal Property Supplement - Important Flood Insurance Notice
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
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 Auto Application Section
38 OR
2013/01
Oregon Notice of Information Practices (Privacy)
North Carolina Property Supplement - Prop Ins Notice Disclosure
61 OR
2016/01
Oregon Auto Supplement - UM Coverage Selection
North Carolina Auto Supplement - Notice of Right to Purchase Higher Limits of Uninsured Motorist (UM) and Underinsured Motorist (UIM) Coverage
62 OR
2006/01
Oregon Personal Lines Supplement
90 OR
2016/01
Oregon Personal Auto Application
New York
70 NY 90 NY
2006/04 2015/12
137 NY 2015/12
NYPIUA Instructions for Completing ACORD 177 NY New York Personal Auto Application
138 NY 2015/12
New York Garage and Dealers
171 NY
New York Notice of Election of a Corporation
172 NY 173 NY 174 NY 177 NY 290 NY 855 NY
10/96 7/96
New York Election of Partners or Self-Employed Persons for Workers’ Compensation Coverage
7/96
New York Election of Executive Officers of an Organization for Workers’ Compensation Coverage
7/96
New York Revocation of Executive Officers of an Organization for Workers’ Compensation Coverage
2006/04 2015/12 2014/05
NYPIUA Application for Commercial Insurance New York Personal Auto Application Section New York Construction Certificate of Liability Insurance Addendum
North Carolina 64 NC
65 NC
2008/04
2010/02
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
66 NC
Oklahoma
New York Commercial Auto
90 NC
2016/05
North Carolina Personal Auto Application
135 NC
2015/10
North Carolina Workers Comp Insurance Plan - Application
136 NC
2015/10
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
Oregon
137 OR 2016/01
Oregon Commercial Auto
138 OR 2016/01
Oregon Garage and Dealers
290 OR 2016/01
Oregon Personal Auto Application Section
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 8 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS - continued #
Current
Future
Title
Quantity
#
Current
Pennsylvania
Future
Title
Quantity
South Carolina
50 PA
2007/09
Pennsylvania Financial Responsibility Card
50 SC
2007/01
South Carolina Insurance Identification Card
60 PA
2012/10
Pennsylvania UM Coverage Select/Reject
61 SC
2007/08
61 PA
2014/02
Pennsylvania Auto Supplement - Important Notice
South Carolina Auto Supplement - Offer of Opt UM/UIM Coverage
62 PA
2012/10
Pennsylvania UIM Coverage Select/Reject
64 SC
2008/03
South Carolina Personal Property Supplement - Cancellation Rules Disclosure
64 PA
2015/05
Insurance Placement Facility of Pennsylvania Basic Property Insurance Application
90 SC
2015/12
South Carolina Personal Auto Application
65 PA / DE 2015/05 / WV
137 SC 2015/12
South Carolina Commercial Auto
FAIR Plan Supplementary Questionnaire
138 SC 2015/12
South Carolina Garage and Dealers
2014/12
South Carolina Personal Automobile Application Section
66 PA
2015/05
Insurance Placement Facility of Pennsylvania Dwelling Property 2 - Broad Form Application Supplement
290 SC
90 PA
2015/12
Pennsylvania Personal Auto Application
50 SD
2007/02
South Dakota Insurance Identification Card
137 PA 2015/12
Pennsylvania Commercial Auto
61 SD
2013/02
South Dakota Personal Umbrella Supplement
138 PA 2015/12
Pennsylvania Garage and Dealers
90 SD
2015/12
South Dakota Personal Auto Application
171 PA 2002/02
Pennsylvania Application for Executive Officer Exception
137 SD 2015/12
South Dakota Commercial Auto
172 PA 2002/02
Pennsylvania Executive Officers Declaration
138 SD 2015/12
South Dakota Garage and Dealers
290 PA
Pennsylvania Personal Auto Application Section
180 SD 2016/03
South Dakota Technology E&O Section
290 SD
2014/12
South Dakota Personal Auto Application Section
50 TN
2007/02
Tennessee Insurance Identification Card
90 TN
2015/12
Tennessee Personal Auto Application
2015/12
Puerto Rico
South Dakota
Tennessee
90 PR
2015/12
Puerto Rico Personal Auto Application
290 PR
2014/12
Puerto Rico Personal Auto Application Section
50 RI
2008/01
Rhode Island Insurance Identification Card
137 TN 2015/12
Tennessee Commercial Auto
61 RI
2012/12
Rhode Island Auto Supplement, Uninsured / Underinsured Motorist Bodily Injury Coverage
138 TN 2015/12
Tennessee Garage and Dealers
290 TN 2014/12
Tennessee Personal Automobile Application Section
50 TX
2015/05
Texas Liability Insurance Card
60 TX
2016/03
Texas Consumer Bill of Rights for Personal Auto
62 TX
2016/03
Texas Consumer Bill of Rights for Personal Auto (Spanish)
Rhode Island
62 RI
2006/01
Rhode Island Prop Suppl - Notice of Flood Coverage Exclusion
64 RI
2012/07
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 Application ACORD 64 RI
64 TX
2003/04
Texas Windstorm Insurance Association Application
2012/07
Rhode Island Joint Underwriting Insurance Application for Dwelling Fire and Personal Liability Insurance Inspection and Placement
67 TX
2016/03
Texas Homeowners and Personal Property - Rights
Rhode Island Joint Underwriting Insurance Inspection Notice, Credit Reporting Notice and Instructions for Completing Dwelling Fire and Personal Liability Application ACORD 66 RI
68 TX
2016/03
Texas Homeowners and Personal Property - Rights (Spanish)
69 TX
2000/08
Texas Special Mobile Home Windstorm/Haill Application
90 TX
2015/12
Texas Personal Auto Application
66 RI
67 RI
68 RI
69 RI
2007/03
2003/04
2003/04
Rhode Island Joint Underwriting Insurance Application for Commercial Fire Insurance Inspection and Placement Rhode Island Joint Underwriting Insurance Inspection Notice, Credit Reporting Notice and Instructions for Completing Commercial Fire Application ACORD 68 RI
Texas
137 TX 2015/12
Texas Commercial Auto
138 TX 2015/12
Texas Garage and Dealers
290 TX 2015/12
Texas Personal Automobile Application Section TX Personal Lines Supp. - Use of Credit Information Disclosure
90 RI
2015/12
Rhode Island Personal Auto Application
851 TX 2010/06
137 RI
2015/12
Rhode Island Commercial Auto
852 TX 2010/06
138 RI
2015/12
Rhode Island Garage and Dealers
TX Personal Lines Supp. (Spanish Version) - Use of Credit Information Disclosure
853 TX 2014/01
Texas Personal Property Supplement
290 RI
2016/06
Rhode Island Personal Automobile Application Section 854 TX 2012/08
Texas Risk Pool Certificate of Property Coverage
855 TX 2015/02
Texas Risk Pool Certificate of Liability Coverage
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 9 of 12
ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS - continued #
Current
Future
Title
Quantity
#
Current
United States 60 US 62 US 64 US
Future
Title
Quantity
West Virginia
2015/01
Insurance Supplement - Offer of Terrorism Coverage
38 WV
2006/04
West Virginia Personal Insurance Supplement Notice of Insurance Information Practices
2015/01
Insurance Supplement - Offer of Terrorism Coverage Standard Fire Policy Only
50 WV
2014/01
West Virginia Certificate of Insurance
2015/01
Insurance Supplement - Offer of Terrorism Coverage Workers Compensation
60 WV
2016/01
West Virginia Auto Supplement - UM / UIM Vehicle Coverage
61 WV
2016/01
West Virginia Auto Supplement - UM / UIM Coverage Offer Split Limits
Utah 2014/07
Utah Insurance Identification Card
62 WV
2016/01
West Virginia Auto Supplement - UM / UIM Coverage Offer Single Limits
61 UT
2013/04
Utah Auto Supplement Uninsured / Underinsured Motorist Coverage Selection
64 WV
2015/05
63 UT
9/93
Utah Fraud Statement
West Virginia Essential Property Insurance Association Basic Property Insurance Application
65 WV
2016/01
West Virginia Umbrella Liability Supplement Important Notice
66 UT
6/94
Utah Arbitration Provisions
67 UT
10/94
90 UT
51 UT
Utah Auto Supplement PIP Coverage, Loss of Income Waiver
65 PA / DE 2015/05 / WV
FAIR Plan Supplementary Questionnaire
2015/12
Utah Personal Auto Application
66 WV
2016/01
137 UT
2015/12
Utah Commercial Auto
West Virginia Personal and Commercial Umbrella Liability Supplement - UM / UIM Coverage - Offer of Split Limits
138 UT
2015/12
Utah Garage and Dealers
67
2015/07
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement
290 UT 2014/12
Utah Personal Auto Application Section
68 WV
2016/01
West Virginia Umbrella Liability Supplement UM / UIM Coverage - Offer of Single Limits
90 WV
2015/12
West Virginia Personal Auto Application
50 VT
Vermont Automobile Insurance Identification Card
Vermont 66 VT 90 VT
2007/02 2003/06 2015/12
137 WV 2015/12
West Virginia Commercial Auto
138 WV 2015/12
West Virginia Garage and Dealers
290 WV 2014/12
West Virginia Personal Auto Application Section
862 WV 2005/07
West Virginia Property Supplement - Notice of Flood Coverage Exclusion
4 WI
2003/04
Wisconsin Employers First Report of Injury or Disease
Vermont Insurance Supplement - Fair Credit Reporting Act Vermont Personal Auto Application
137 VT 2015/12
Vermont Commercial Auto
138 VT 2015/12
Vermont Garage and Dealers
290 VT 2014/12
Vermont Personal Auto Application Section
Virgin Islands
Wisconsin
90 VI
2015/12
Virgin Islands Personal Auto Application
90 WI
2015/12
Wisconsin Personal Auto Application
137 VI
2014/08
Virgin Islands Commercial Auto
97 WI
2003/10
138 VI
2015/06
Virgin Islands Garage and Dealers
Wisconsin Automobile Insurance Plan Private Passenger Auto Application
133 WI
2010/04
Wisconsin Workers Compensation Insurance Pool
290 VI
2014/12
Virgin Islands Personal Auto Application Section 134 WI
8/99
Wisconsin Supplementary Non-Election Form
135 WI
8/99
Wisconsin Supplementary Election of Coverage Form
Virginia 38 VA
2011/05
Virginia Notice of Information Practices (Privacy)
60 VA
8/94
Virginia Auto Supplement - Rental Reimbursement Coverage
136 WI
2010/04
Wisconsin Supplement Limited Other States Coverage Request
62 VA
6/97
Virginia Property Supplement Ordinance or Law Coverage; Additional Cov Available
137 WI
2015/12
Wisconsin Commercial Auto
138 WI
2015/12
Wisconsin Garage and Dealers
2011/11
Wisconsin Automobile Insurance Plan Business Auto Application
64 VA
2005/01
Virginia Property Supplement - Notice of Flood Insurance
67 VA
2000/11
Virginia Property Insurance Association
177 WI
90 VA
2015/12
Virginia Personal Auto Application
178 WI
2011/11
Wisconsin Automobile Insurance Plan - Truckers Application
137 VA 2015/12
Virginia Commercial Auto
290 WI
2016/06
Wisconsin Personal Auto Application Section
138 VA 2015/12
Virginia Garage and Dealers
290 VA 2014/12
Virginia Personal Auto Application Section
90 WY
2015/12
Wyoming Personal Auto Application
137 WY 2015/12
Wyoming Commercial Auto
90 WA
Washington Personal Auto Application
138 WY 2015/12
Wyoming Garage and Dealers
137 WA 2015/12
Washington Commercial Auto
290 WY 2014/12
Wyoming Personal Auto Application Section
138 WA 2015/12
Washington Garage and Dealers
290 WA 2014/12
Washington Personal Auto Application Section
Washington 2015/12
Wyoming
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, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 10 of 12
ACORD Forms Index ACORD Australia Forms - Available ONLY on the ACORD Web Site AUSTRALIA FORMS 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
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
Edition
Title
ACORD Forms Index (rev. 05-31-2016) Page 11 of 12
ACORD Forms Index ACORD Life/Annuity/Health Forms - Available ONLY on the ACORD Web Site COUNTRYWIDE LIFE FORMS Number
Edition
Title
Edition
Title
650
2013/01
Authorization for the Release of Health Information
794
Number
2012/01
Request for Proposal - Dental and Vision Supplement
651
2007/07
Electronic Funds Transfer Authorization Form for Long Term Care Insurance
821
2015/10
Producer Information Form (PIF)
652
2007/07
Credit Card Payment Authorization Form for Long Term Care Insurance
876
2015/10
Background Check Authorization
653
2008/04
Policy Delivery Receipt
877
2015/10
731
2010/05
Request for Proposal - Additional Unions Schedule
Disclosure of Intent to Obtain Consumer Report or Investigative Consumer Report (except California)
951
2013/10
1035 Exchange / Rollover / Transfer Form
732
2010/05
Request for Proposal - Additional Locations Schedule 951e
2015/12
1035 Exchange / Rollover / Transfer eForm
Edition
Title
751 NY
2005/11
New York Authorization to Obtain and Disclose Information
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 Condition Details / Additional Care Providers
785
2011/07
Request for Proposal - Employee Benefits
786
2011/09
Request for Proposal - Life Supplement
787
2011/12
Request for Proposal - Short Term Disability Supplement
788
2010/05
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
Edition
Title
STATE LIFE FORMS Number
Number
Arkansas
New York
966 AR
2007/03
Arkansas Annuity Product Comparison Form
753 NY
2005/11
New York Notice of Insurance Information Practices (Pre Notice)
757 CA
2004/07
California HIV Antibody/Antigen Consent and Testing Form
757 NY
2005/11
New York HIV Antibody/Antigen Consent and Testing Form
760 CA
2015/06
California Notice Regarding Replacement
960 NY
2007/03
New York Disclosure Statement Annuity to Annuity Replacements Only
877 CA
2015/10
California Disclosure of Intent to Obtain an Investigative Consumer Report
966 CA
2007/03
California Annuity Product Comparison Form
757 OH
2009/02
Ohio HIV Antibody/Antigen Consent and Testing Form
757 DC
2004/07
District of Columbia HIV Antibody/Antigen Consent and Testing Form
757 OR
2004/07
Oregon HIV Antibody/Antigen Consent and Testing Form
766 RI
2007/03
Rhode Island Life Product Comparison Form
757 TX
2004/11
Texas HIV Antibody/Antigen Consent and Testing Form
655 VA
2010/12
Virginia Group Health Insurance - Medical History Form
757 WA
2010/05
Washington HIV Antibody/Antigen Consent and Testing Form
760 WA
2015/06
Washington Important Notice Regarding Replacement
California
Ohio
District of Columbia
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
966 FL
2007/03
Florida Annuity Product Comparison Form
969 FL
2007/03
Florida Annuity Product Comparison Form Supplement - Policy / Rider Description
760 ID
2007/03
Idaho Important Notice Regarding Replacement
757 MA
2004/11
Massachusetts HIV Antibody/Antigen Consent and Testing Form
760 MA
2015/06
Massachusetts Important Notice Regarding Replacement
757 MI
2004/12
Michigan HIV Antibody/Antigen Consent and Testing Form
760 MN
2015/12
Minnesota Notice Regarding Replacement
Oregon Rhode Island Texas Virginia
Idaho Massachusetts
Washington
Michigan Minnesota
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600 All forms are available for download on the ACORD web site (http://www.acord.org)
ACORD Forms Index (rev. 05-31-2016) Page 12 of 12
