Motor Vehicle Financial Responsibility Forms

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1 Alphabetical Index Forms are listed alphabetically by form title. Important Note: The forms shown herein for each state may not be a complete listing of all the financial responsibility forms that are required for the state. Some forms are not stocked by WOLTERS KLUWER FINANCIAL SERVICES because of their infrequent use (resulting in little demand) or because supplies are available from a state source. The state usage indicated for the various forms was based on the best information we had at the time of publication. You should be guided by individual state requirements. When using Acord Forms, user should be guided by instruction from the Acord Corporation. PAGE MC 1 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

2 MULTI-STATE AAMVA FORMS These forms are based on text suggested by the American Association of Motor Vehicle Administrators (AAMVA) for multi-state application. Numerous states have adopted these forms and such is so indicated in the state listings herein, except as noted for SR-21 and SR-24. SR-23 does not apply in the county of Honolulu. * (F) R1302 A 10/91 SR FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY (N) R1303 A 10/91 SR23 NOTICE FOR FLEETS AK, AL, AR, AZ, CO, CT, DC, FL, GA, HI, IA, ID, IN, LA, MS, MT, ND, NH, NM, NV, OH, OK, OR, RI, SC, TN, TX, VA, WA, WI, WV, WY R1307 A 10/91 SR26 NOTICE OF CANCELLATION OR TERMINATION AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY R1305 A 10/91 SR24 NOTICE OF CHANGE AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY R1300 A 10/91 SR21 NOTICE OF POLICY (UNIFORM HAS NO INDICATION OF THE STATE USAGE FOR THIS FORM, BUT THERE CONTINUES TO BE A SUBSTANTIAL DEMAND FOR IT AND, THEREFORE, WE WILL MAINTAIN IT AS A STOCK ITEM.) GENERAL USE/STATE SPECIFIC Alabama ACORD50AL 10/07 ACORD50AL 10/07 ALABAMA INSURANCE IDENTIFICATION R1451 A 07/01 ALABAMA MOTOR VEHICLE INSURANCE R /06 SR-21 PROOF OF LIABILITY INSURANCE - ALABAMA R /01 TEMPORARY MOTOR VEHICLE INSURANCE Alaska PAGE MC 2 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

3 R1355 SR-22 CERTIFICATE OF INSURANCE ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Arizona ACORD50AZ 03/10 ACORD50AZ ARIZONA INSURANCE IDENTIFICATION R1371 C 06/01 INSURANCE ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Arkansas ACORD50AR 10/07 ACORD50AR 10/07 ARKANSAS PROOF OF INSURANCE R1320 C 09/07 R1320C 09/07 AUTOMOBILE INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE R1443 A 08/05 SR10805 MOTOR VEHICLE ACCIDENT REPORT R /01 PROOF OF LIABILITY INSURANCE FOR MOTORBOAT OR WATERCRAFT California ACORD51CA 07/04 ACORD51CA CALIFORNIA EVIDENCE OF LIABILITY INSURANCE ACORD50CA 07/04 ACORD50CA0704 CALIFORNIA INSURANCE R1406 P 09/08 SR10908 CALIFORNIA TRAFFIC ACCIDENT REPORT R /00 COMMERCIAL/FLEET AUTOMOBILE INSURANCE R1331 C 08/91 SR75 EMPLOYER'S INSURANCE CERTIFICATE R1435 A 01/04 REG890AREV597 EVIDENCE OF LIABILITY INSURANCE R1349 B 06/00 SR22SR1P INSURANCE PROOF CERTIFICATE R1332 D 11/91 SR76 NOTICE OF CANCELLATION R1330 G 10/07 SR-26/SR-1PF NOTICE OF CANCELLATION INSURANCE PROOF CERTIFICATE R /00 PRIVATE PASSENGER AUTOMOBILE INSURANCE R1465 A 12/07 SR19C1207 REQUEST FOR INFORMATION (INSURANCE INFORMATION, UNINSURED MOTORIST CERTIFICATION, PHOTO COPY OF SR1 REPORT) R /04 REG481REV82003 SALVAGE VEHICLE NOTICE OF RETENTION BY OWNER PAGE MC 3 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

4 Colorado ACORD50CO 03/07 ACORD50CO COLORADO AUTO INSURANCE R1321 A 07/03 (FOR USE WITH POLICIES ISSUED 7/1/03 OR AFTER) ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Connecticut ACORD50CT 01/09 ACORD50CT CONNECTICUT INSURANCE R1311 E 10/08 (PERMANENT) R1317 C 02/01 (TEMPORARY) R1399 A 05/10 INSURANCE (PERMANENT - FOR COMMERCIAL MOTOR VEHICLES) R1325 D 06/06 IRB3613C SPECIAL FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE GU1327 G 07/09 IRB 3616D SPECIAL NOTICE OF CANCELLATION OR TERMINATION MC /00 VANPOOL INSURANCE CERTIFICATE Delaware R /91 FR4 01/94 ASSIGNED RISK INSURANCE CERTIFICATE REQUEST R /08 DELAWARE INSURANCE COMMERCIAL/ FLEET R1388 A (New) R1356 A 09/07 FR19 INSURANCE CERTIFICATE R /91 LETTER OF TRANSMITTAL (FOR USE WITH R1350) R /91 LISTING OF VEHICLES INSURED R1359 A 09/07 FR4 09/07 NOTICE OF CANCELLATION OR TERMINATION OF POLICY R /91 FR10490 UNINSURED VEHICLE REPORT District of Columbia ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Florida R /74 AUTOMOBILE INSURANCE BINDER R /71 SR22 06/71 FINANCIAL RESPONSIBILITY FORM ACORD51FL 07/09 ACORD51FL(2009/07) FLORIDA COMMERCIAL AUTO INSURANCE R1410 D (AUTOMOBILE INSURANCE) R1384 PAGE MC 4 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

5 (FOR USE WITH PRIVATE PASSENGER MOTOR VEHICLE INSURANCE POLICY) R /07 FR UNIFORM FINANCIAL RESPONSIBILITY CERTIFICATE R /07 FR UNIFORM FINANCIAL RESPONSIBILITY CERTIFICATE NOTICE OF CANCELLATION Georgia R /76 AUTHORIZATION TO OBTAIN DRIVER RECORD INFORMATION FROM GEORGIA DEPARTMENT OF PUBLIC SAFETY (FLEET COMMERCIAL RISKS) R1417 B 12/03 FLEET POLICY INFORMATION ACORD50GA 11/08 ACORD50GA0811 GEORGIA INSURANCE POLICY INFORMATION R /03 INSURANCE POLICY INFORMATION NON FLEET R1385 A 01/92 REQUEST FOR MOTOR VEHICLE REPORT R1309 D 10/06 SR22A SAFETY RESPONSIBILITY INSURANCE CERTIFICATE Hawaii ACORD50HI 01/08 ACORD50HI0199 HAWAII MOTOR VEHICLE INSURANCE R1304 C 01/99 INSURANCE Idaho R1419 A 07/83 CERTIFICATE OF LIABILITY INSURANCE ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE ACORD50ID 10/07 ACORD50ID 10/07 STATE OF IDAHO LIABILITY INSURANCE Illinois R /71 SR22A 06/71 (IL) CERTIFICATE R /09 SR-22 FINANCIAL RESPONSIBILITY CERTIFICATE R /09 SR-26 FINANCIAL RESPONSIBILITY NOTICE OF CANCELLATION OR TERMINATION ACORD50IL 03/07 ACORD50IL ILLINOIS INSURANCE IDENTIFICATION R1341 A 07/96 INSURANCE Indiana R1461 C 03/ R3 AFFIDAVIT OF CURRENT INSURANCE "SR-50" R1432 C 03/ R5305 CERTIFICATE OF COMPLIANCE R /94 CERTIFICATE OF COMPLIANCE (WITH CARE LESSOR'S/EMPLOYER'S AFFIDAVIT) ACORD50IN 11/07 ACORD50 IN INDIANA INSURANCE IDENTIFICATION PAGE MC 5 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

6 R / /SR21 INDIANA OPERATOR'S PROOF OF INSURANCE/CRASH REPORT ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Iowa ACORD50IA 08/07 ACORD50IA0807 INSURANCE R1437 A 11/08 IOWA FINANCIAL LIABILITY COVERAGE Kansas R /84 SR AAMVA UNIFORM FINANCIAL RESPONSIBILITY FORM R1308 C 07/10 (AUTO LIABILITY INSURANCE) ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Kentucky ACORD50KY 01/06 ACORD50KY COMMONWEALTH OF KENTUCKY PROOF OF INSURANCE R1322 D 01/09 PROOF OF INSURANCE Louisiana R1318 A 01/96 (AUTO INSURANCE) ACORD50LA 03/08 ACORD50LA(2008/03) LOUISIANA AUTO INSURANCE ID Maine R /71 CERTIFICATE DEALERS R /88 (MOTOR VEHICLE INSURANCE) ACORD50ME 08/07 ACORD50ME0807 MAINE MOTOR VEHICLE INSURANCE Maryland R1403 E 03/09 FR-19 03/09 INSURANCE CERTIFICATION ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Massachusetts ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD PAGE MC 6 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

7 INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Michigan R1408 A 04/81 CERTIFICATE OF NO-FAULT INSURANCE (NOT FOR USE WHEN POLICY CONTAINS NAMED-DRIVER EXCLUSION) R /92 FR NOTICE OF CANCELLATION (FINANCIAL RESPONSIBILITY CERTIFICATE) R /94 FR201A0194 OPERATOR'S POLICY CERTIFICATE R /75 FR OWNERS POLICY CERTIFICATE ACORD50MI 08/10 ACORD50MI STATE OF MICHIGAN CERTIFICATE OF NO-FAULT INSURANCE Minnesota ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE R1313 A 01/93 MOTOR VEHICLE INSURANCE R /99 SUPPLEMENT TO MINNESOTA MOTOR VEHICLE INSURANCE IDENTIFICATION (SUMMARY OF CRIMINAL PENALTIES) Mississippi R /00 INSURANCE ACORD50MS 01/01 ACORD50MS0101 MISSISSIPPI INSURANCE Missouri R /71 SR22A 06/71 (MO) CERTIFICATE R /87 (AUTOMOBILE INSURANCE) ACORD50MO 05/07 ACORD50MO MISSOURI AUTO INSURANCE Montana MC /03 MV-5C REV12/03 CANCELLATION OF CERTIFICATE OF INSURANCE - TOW TRUCKS OPERATIONS R1374 (I.D. STOCKED IN PERFORATED STRIPS OF 3 S. ORDER BY QUANTITY OF S DESIRED NOT BY THE STRIP.) ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE PAGE MC 7 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

8 Nebraska ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE R /86 MOTOR VEHICLE LIABILITY INSURANCE CERTIFICATE (I.D. ) ACORD50NE 01/07 ACORD50NE NEBRASKA AUTO LIABILITY INSURANCE Nevada R1351 E 08/10 EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE R1456 A 08/10 EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE - FOR OPERATOR USE ACORD52NV 05/10 ACORD52NV 2010/05 NEVADA PERMANENT INSURANCE ACORD51NV 05/10 ACORD51NV 2010/05 NEVADA TEMPORARY INSURANCE ID ACORD51NV 11/08 ACORD51NV NEVADA TEMPORARY INSURANCE ID R1354 E 08/10 TEMPORARY EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE R1457 A 08/10 TEMPORARY EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE - FOR OPERATOR USE New Hampshire ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE New Jersey R1401 C 05/04 INSURANCE ACORD50NJ 03/07 ACORD 50 NJ NEW JERSEY INSURANCE (WITH WATERMARK) R /04 TEMPORARY EVIDENCE OF INSURANCE R1402 D 05/04 TEMPORARY NEW JERSEY INSURANCE New Mexico R /84 (PROOF OF FINANCIAL RESPONSIBILITY) ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE PAGE MC 8 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

9 New York R1455 A 12/02 MV DMV ODOMETER AND DAMAGE DISCLOSURE STATEMENT R1393 K 07/05 MV104 05/02 REPORT OF MOTOR VEHICLE ACCIDENT R /02 MV104B0502 REPORT OF MOTOR VEHICLE ACCIDENT North Carolina R1379 C 09/99 FS1* CERTIFICATE OF LIABILITY INSURANCE R1310 A 10/89 DL DRIVERS LICENSE LIABILITY INSURANCE CERTIFICATION ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE R1381 D 09/99 FS-4 NOTICE OF TERMINATION OF LIABILITY INSURANCE MC1720 A 02/06 MVR4CREV NOTIFICATION OF OWNER RETAINED VEHICLE North Dakota R1446 A 09/04 SFN CERTIFICATE OF MOTOR VEHICLE LIABILITY INSURANCE - NORTH DAKOTA ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE ACORD50ND 08/07 ACORD50ND NORTH DAKOTA INSURANCE Ohio R1467 A 09/10 BMV3303 CRASH REPORT ACORD50 02/07 ACORD INSURANCE R /95 INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Oklahoma R1319 C 11/09 (OWNER'S AND OPERATOR'S SECURITY VERIFICATION FORM) ACORD51OK 08/09 ACORD51OK OKLAHOMA OPERATORS SECURITY VERIFICATION FORM ACORD50OK 08/09 ACORD50OK OKLAHOMA OWNERS SECURITY VERIFICATION FORM MOTOR VEHICLE COPY Oregon ACORD50 02/07 ACORD INSURANCE PAGE MC 9 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

10 AC5012 A 02/07 ACORD INSURANCE (2 UP) R /93 INSURANCE (I.D. STOCKED IN PERFORATED SHEETS OF 12 S. ORDER BY QUANTITIES OF S DESIRED NOT BY SHEET) AC5011 A 02/07 ACORD INSURANCE Pennsylvania R /04 MV6SV0203 APPLICATION FOR CERTIFICATE OF SALVAGE FOR A STOLEN VEHICLE MV6 A 04/09 MV-6 APPLICATION FOR NON REPAIRABLE OR SALVAGE CERTIFICATE R1413 E 08/98 FINANCIAL RESPONSIBILITY R1378 H 02/94 FR40180 NOTICE OF PROPOSED SUSPENSION OF VEHICLE REGISTRATION ACORD50PA 09/07 ACORD50PA PENNSYLVANIA FINANCIAL RESPONSIBILITY Rhode Island R1431 C 01/08 INSURANCE ACORD50RI 01/08 ACORD50RI RHODE ISLAND INSURANCE GU1338 D 10/07 IRB3676 SPECIAL FINANCIAL RESPONSIBILITY INSURANCE CERTIFICATE South Carolina R /94 SR 21 FINANCIAL RESPONSIBILITY FORM R /00 MOTOR VEHICLE INSURANCE R /97 PROOF OF FINANCIAL RESPONSIBILITY (STOCKED IN PERFORATED STRIPS OF 3 S. ORDER BY QUANTITY OF S DESIRED NOT NUMBER OF STRIPS) ACORD50SC 01/07 ACORD50SC SOUTH CAROLINA INSURANCE South Dakota R1426 (PERMANENT) R1427 (TEMPORARY) ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE ACORD50SD 02/07 ACORD50SD SOUTH DAKOTA INSURANCE Tennessee R1342 A 09/00 JR22 CERTIFICATE (UNDER AGED DRIVERS) R /01 MOTOR VEHICLE INSURANCE R /71 JR23 PAGE MC 10 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

11 NOTICE OF CANCELLATION (UNDER AGED DRIVERS) MC /00 SF-0395 OWNER/DRIVER REPORT ACORD50TN 02/07 ACORD50TN TENNESSEE INSURANCE Texas R1339 B 11/01 LIABILITY INSURANCE CR1367 A 10/01 LIABILITY INSURANCE (IN ENGLISH/SPANISH) R1367 A 10/01 LIABILITY INSURANCE (IN ENGLISH/SPANISH) R1454 A 05/02 LIABILITY INSURANCE (IN ENGLISH/SPANISH)(WITH PANTO) R /91 LIABILITY INSURANCE (IN SPANISH) ACORD50TX 11/08 TEXAS INSURANCE IDENTIFICATION Utah R1407 A 03/75 (INSURANCE) ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Vermont R /86 (AUTOMOBILE INSURANCE) ACORD50VT 02/07 ACORD50VT VERMONT AUTOMOBILE INSURANCE Virginia R1333 B 02/08 VSA 57 APPLICATION FOR NON-REPAIRABLE CERTIFICATE VIRGINIA R1324 B 12/08 VSA 56 APPLICATION FOR SALVAGE CERTIFICATE VIRGINIA R1344 A 04/93 LSD 03 4/93 CERTIFICATION OF RECOVERED STOLEN VEHICLE R /03 FR10197 INSURANCE COVERAGE REPORT ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE R /08 NOTICE OF CANCELLATION OR TERMINATION (FR-46) R /08 UNIFORM FINANCIAL RESPONSIBILITY CERTIFICATE (FR-44) Washington ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) PAGE MC 11 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

12 AC5011 A 02/07 ACORD INSURANCE R1471 B 03/09 TD TOTAL LOSS CLAIM SETTLEMENT REPORT West Virginia R1346 B 04/84 WV1B CERTIFICATE OF INSURANCE (I.D. STOCKED IN PERFORATED STRIPS OF 3 S. ORDER BY QUANTITY OF S DESIRED NOT BY THE STRIP.) R1360 D 05/08 WV-2B NOTICE OF CANCELLATION/ TERMINATION - WEST VIRGINIA ACORD50WV 04/08 ACORD50WV (04/08) WEST VIRGINIA CERTIFICATE OF INSURANCE Wisconsin ACORD50 02/07 ACORD INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE Wyoming ACORD50 02/07 ACORD INSURANCE R /92 INSURANCE AC5012 A 02/07 ACORD INSURANCE (2 UP) AC5011 A 02/07 ACORD INSURANCE PAGE MC 12 of 12 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

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