SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2...

Transcription

1 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto Filing at a Glance Company: ACORD Corporation Product Name: ACORD 137 WI (2014/12) Commercial Auto State: TOI: Sub-TOI: Filing Type: Wisconsin 20.0 Commercial Auto Business Auto Form Date Submitted: 01/15/2014 SERFF Tr Num: SERFF Status: State Tr Num: State Status: ACPC Closed-Filed Co Tr Num: ACORD 137 WI (2014/12) COMMERCIAL AUTO Effective Date Requested (New): Effective Date Requested (Renewal): Author(s): Reviewer(s): 12/01/ /01/2014 Disposition Date: 01/15/2014 Disposition Status: Ellen Brophy, Anthony Bolonga, Jean Carlos, Joel Volker, Kori Johanson, Carmen Belen Shasta Hoffhein (primary) Filed Effective Date (New): 02/13/2014 Effective Date (Renewal): 02/13/2014 PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

2 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto General Information Project Name: ACORD 137 WI (2014/12) Commercial Auto Project Number: ACORD 137 WI (2014/12) Commercial Auto Reference Organization: ACORD Reference Title: Wisconsin Commercial Auto Filing Status Changed: 01/15/2014 Status of Filing in Domicile: Domicile Status Comments: Reference Number: ACORD 137 WI (2014/12) Commercial Auto Advisory Org. Circular: ACORD 137 WI State Status Changed: Deemer Date: 02/13/2014 Created By: Jean Carlos Corresponding Filing Tracking Number: ACORD 137 WI (2014/12) Commercial Auto Filing Description: January 15, 2014 Submitted By: Jean Carlos Ms. Catherine Otis Bureau of Market Regulation Wisconsin Office of the Commissioner of Insurance P.O. Box #7873 Madison, WI RE: Rate Service Organization Forms Filing ACORD Forms Filing (Commercial Auto) ACORD 137 WI (2014/12) Wisconsin Commercial Auto Dear Ms. Otis: As a rate service organization, we hereby make a form filing on behalf of ACORD s affiliated companies. Attached are the following: 1. ACORD Cover Letter 2. Property and Casualty Transmittal Document PC TD-1 3. Form Filing Schedule PC FFS-1 4. ACORD Certificate of Compliance 5. WI Certificate of Compliance and Readability 6. Certificate of Readability 7. Explanation of Changes/Use 8. ACORD Application that is being filed (Attached to Forms Schedule) Please do not hesitate to contact me at or cbelen@acord.org if I can answer any questions about this submission. We look forward to working with you on this filing. Sincerely, PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

3 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto Carmen M. Belen, CCP, CPCU, AINS, ARM, AIS Senior Regulatory Analyst Company and Contact Filing Contact Information Carmen Belen, 2 Blue Hill Plaza 3rd Floor Pearl River, NY Filing Company Information ACORD Corporation One Blue Hill Plaza 15th Floor Pearl River, NY (800) ext. [Phone] cbelen@acord.org [Phone] CoCode: 44 Group Code: Group Name: ACORD Corporation FEIN Number: State of Domicile: Delaware Company Type: SDO- Advisory/Rate Seve State ID Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: No No PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

4 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto Correspondence Summary Dispositions Status Created By Created On Date Submitted Filed Shasta Hoffhein 01/15/ /15/2014 PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

5 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto Disposition Disposition Date: 01/15/2014 Effective Date (New): 02/13/2014 Effective Date (Renewal): 02/13/2014 Status: Filed Comment: Used with form filings that are subject to file & use under s (1)(c) and (1m) Wis. Stat. Effective July 1st, 2008, changes in insurance law exempted certain policy forms from receiving prior approval before use. This filing may be used 30 days after receipt by OCI. USE DATE:02/13/2014 Rate data does NOT apply to filing. Schedule Schedule Item Schedule Item Status Public Access Supporting Document Certification of Compliance and Readability Filed Yes Supporting Document Appraisal or Arbitration Provision Filed Yes Supporting Document ACORD Cover Letter (137 WI-Commecial Auto) Filed Yes Supporting Document CERTIFICATE OF COMPLIANCE Filed Yes Supporting Document CERTIFICATE OF READABILITY Filed Yes Supporting Document P&C TRANSMITTAL FORM (137 WI- Filed Yes Commercial Auto) Supporting Document WISCONSIN FORMS LIST Filed Yes Supporting Document forms_index Filed Yes Supporting Document ACORD 137 WI (2014/12) Explanation of Changes Filed Yes Form Wisconsin Commercial Auto Filed Yes PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

6 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto Form Schedule Item Schedule Item Form No. Status Name 1 Filed 01/15/2014 Wisconsin Commercial Auto Form Number ACORD 137 WI Edition Form Form Action Specific Date Type Action Data 2014/12 ABE Replaced Previous Filing Number: Replaced Form Number: ACPC ACORD 137 WI (2011/12) Readability Score Attachments 137 WI pdf Form Type Legend: ABE Application/Binder/Enrollment ADV Advertising BND Bond CER Certificate CNR Canc/NonRen Notice DEC Declarations/Schedule DSC Disclosure/Notice END Endorsement/Amendment/Conditions ERS Election/Rejection/Supplemental Applications OTH Other PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

7 AGENCY AGENCY CUSTOMER ID: WISCONSIN COMMERCIAL AUTO COVERAGES / LIMITS SECTION NAMED INSURED(S) DATE (MM/DD/YYYY) POLICY NUMBER EFFECTIVE DATE CARRIER NAIC CODE BUSINESS AUTO SECTION COVERAGES COVERED AUTO SYMBOLS CSL LIMITS BI EA PER COVERAGES COVERED AUTO SYMBOLS LIMITS LIABILITY 2 7 BI EACH ACCIDENT 3 8 PROPERTY DAMAGE PHYSICAL DAMAGE TOWING 3 & LABOR 7 MEDICAL PAYMENTS UNINSURED MOTORIST UNDERINSURED MOTORIST HIRED / BORROWED LIABILITY NON-OWNED LIABILITY COVERED AUTO SYMBOLS YES NO YES NO STATES STATES 9 EACH PERSON CSL CSL (1) ANY AUTO (2) ALL OWNED AUTOS (3) OWNED PRIVATE PASSENGER AUTOS BI EACH ACCIDENT BI EACH ACCIDENT COST OF HIRE GROUP TYPE EMPLOYEES VOLUNTEERS PARTNERS BI EA PER BI EA PER IF ANY BASIS NUMBER OF COMP / OTC SPECIFIED CAUSES OF LOSS COLLISION HIRED PHYSICAL DAMAGE COVERAGE IS: ENDORSEMENTS / REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) STATES (4) OWNED AUTOS OTHER THAN PRIVATE PASSENGER (5) ALL OWNED AUTOS WHICH REQUIRE NO-FAULT COVERAGE (6) OWNED AUTOS SUBJECT TO COMPULSORY U.M. LAW # DAYS # VEH COVERAGE / DEDUCTIBLE PRIMARY COMP SPEC C OF L COLL (7) AUTOS SPECIFIED ON SCHEDULE (8) HIRED AUTOS (9) NON-OWNED AUTOS SECONDARY SIGNATURE I UNDERSTAND AND ACKNOWLEDGE THAT MEDICAL PAYMENTS COVERAGE HAS BEEN OFFERED TO ME. I REJECT THIS COVERAGE ENTIRELY. (INITIALS) I UNDERSTAND AND ACKNOWLEDGE THAT I HAVE BEEN OFFERED UNINSURED AND UNDERINSURED MOTORISTS COVERAGES. I HAVE SELECTED THE LIMIT(S) INDICATED IN THIS APPLICATION. I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING. APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 137 WI (2014/12) Page 1 of ACORD CORPORATION. All rights reserved. Attach to ACORD 127 and/or 132 The ACORD name and logo are registered marks of ACORD

8 TRUCKERS SECTION COVERAGES LIABILITY COVERED AUTO SYMBOLS CSL BI EACH ACCIDENT PROPERTY DAMAGE LIMITS BI EA PER AGENCY CUSTOMER ID: PHYSICAL DAMAGE COVERAGES COVERED AUTO SYMBOLS LIMITS COMP / OTC DEDUCTIBLE MEDICAL PAYMENTS UNINSURED MOTORIST UNDERINSURED MOTORIST NON-TRUCKERS HIRED / BORROWED OTHER YES NO CSL STATES EACH PERSON BI EACH ACCIDENT CSL BI EACH ACCIDENT COST OF HIRE TRUCKERS HIRED / BORROWED YES STATES COST OF HIRE LIABILITY NO NON-OWNED AUTO LIABILITY YES NO STATES GROUP TYPE EMPLOYEES VOLUNTEERS PARTNERS BI EA PER BI EA PER IF ANY BASIS IF ANY BASIS NUMBER OF SPECIFIED CAUSES OF LOSS COLLISION TOWING & LABOR COVERAGES COMP / OTC SPECIFIED CAUSES OF LOSS COLLISION TRAILER VALUE HIRED PHYSICAL DAMAGE TRAILER INTERCHANGE FARTH SYMBOL # TRAILERS ZONE # DAYS STATES # DAYS # VEH SCL F FT FTW LSP RADIUS DEDUCTIBLE OTHER COVERAGE IS: PRIMARY SECONDARY COVERED AUTO SYMBOLS (41) ANY AUTO (42) OWNED AUTOS ONLY (43) OWNED COMMERCIAL AUTOS ONLY (44) OWNED AUTOS SUBJECT TO NO-FAULT (45) OWNED AUTOS SUBJECT TO A COMPULSORY UNINSURED MOTORIST LAW (46) SPECIFICALLY DESCRIBED AUTOS (47) HIRED AUTOS ONLY (48) TRAILERS IN YOUR POSSESSION UNDER A TRAILER INTERCHANGE AGREEMENT ENDORSEMENTS / REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) (49) YOUR TRAILERS IN THE POSSESSION OF ANOTHER TRUCKER UNDER A TRAILER INTERCHANGE AGREEMENT (50) NON-OWNED AUTOS ONLY SIGNATURE I UNDERSTAND AND ACKNOWLEDGE THAT MEDICAL PAYMENTS COVERAGE HAS BEEN OFFERED TO ME. I REJECT THIS COVERAGE ENTIRELY. (INITIALS) I UNDERSTAND AND ACKNOWLEDGE THAT I HAVE BEEN OFFERED UNINSURED AND UNDERINSURED MOTORISTS COVERAGES. I HAVE SELECTED THE LIMIT(S) INDICATED IN THIS APPLICATION. I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING. APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 137 WI (2014/12) Page 2 of 3

9 MOTOR CARRIER SECTION COVERAGES LIABILITY MEDICAL PAYMENTS UNINSURED MOTORIST UNDERINSURED MOTORIST NON-TRUCKERS HIRED / BORROWED CSL BI EA PER 67 BI EACH ACCIDENT TRUCKERS HIRED / BORROWED YES STATES COST OF HIRE LIABILITY NO NON-OWNED AUTO LIABILITY OTHER COVERED AUTO SYMBOLS YES NO YES NO STATES COST OF HIRE CSL BI EACH ACCIDENT PROPERTY DAMAGE LIMITS BI EA PER EACH PERSON 67 BI EACH ACCIDENT STATES CSL GROUP TYPE EMPLOYEES VOLUNTEERS PARTNERS BI EA PER IF ANY BASIS IF ANY BASIS NUMBER OF AGENCY CUSTOMER ID: COVERAGES COMP / OTC SPECIFIED CAUSES OF LOSS COLLISION TOWING & LABOR COVERAGES COMP / OTC SPECIFIED CAUSES OF LOSS COLLISION TRAILER VALUE HIRED PHYSICAL DAMAGE OTHER PHYSICAL DAMAGE COVERED AUTO SYMBOLS LIMITS SCL F FT FTW TRAILER INTERCHANGE FARTH SYMBOL # TRAILERS ZONE # DAYS STATES # DAYS # VEH LSP RADIUS DEDUCTIBLE DEDUCTIBLE COVERAGE IS: PRIMARY SECONDARY COVERED AUTO SYMBOLS (61) ANY AUTO (62) OWNED AUTOS ONLY (63) OWNED PRIVATE PASS AUTOS ONLY (64) OWNED COMMERCIAL AUTOS ONLY (65) OWNED AUTOS SUBJECT TO NO-FAULT (66) OWNED AUTOS SUBJECT TO A COMPUL- SORY UNINSURED MOTORIST LAW (67) SPECIFICALLY DESCRIBED AUTOS (68) HIRED AUTOS ONLY (69) TRAILERS IN YOUR POSSESSION UNDER A TRAILER INTERCHANGE AGREEMENT ENDORSEMENTS / REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) (70) YOUR TRAILERS IN THE POSSESSION OF ANOTHER TRUCKER UNDER A TRAILER INTERCHANGE AGREEMENT (71) NON-OWNED AUTOS ONLY SIGNATURE I UNDERSTAND AND ACKNOWLEDGE THAT MEDICAL PAYMENTS COVERAGE HAS BEEN OFFERED TO ME. I REJECT THIS COVERAGE ENTIRELY. (INITIALS) I UNDERSTAND AND ACKNOWLEDGE THAT I HAVE BEEN OFFERED UNINSURED AND UNDERINSURED MOTORISTS COVERAGES. I HAVE SELECTED THE LIMIT(S) INDICATED IN THIS APPLICATION. I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING. APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 137 WI (2014/12) Page 3 of 3

10 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto Supporting Document Schedules Satisfied - Item: Certification of Compliance and Readability Comments: WI Certificate of Compliance and Readability Attachment(s): WI Certificate of Compliance and Readability pdf Item Status: Filed Status Date: 01/15/2014 Bypassed - Item: Appraisal or Arbitration Provision Bypass Reason: N/A Attachment(s): Item Status: Filed Status Date: 01/15/2014 Satisfied - Item: ACORD Cover Letter (137 WI-Commecial Auto) Comments: ACORD Cover Letter (137 WI-Commecial Auto) Attachment(s): ACORD Cover Letter (137 WI-Commecial Auto).pdf Item Status: Filed Status Date: 01/15/2014 Satisfied - Item: CERTIFICATE OF COMPLIANCE Comments: CERTIFICATE OF COMPLIANCE Attachment(s): CERTIFICATE OF COMPLIANCE pdf Item Status: Filed Status Date: 01/15/2014 Satisfied - Item: CERTIFICATE OF READABILITY Comments: CERTIFICATE OF READABILITY Attachment(s): CERTIFICATE OF READABILITY pdf Item Status: Filed Status Date: 01/15/2014 Satisfied - Item: Comments: Attachment(s): Item Status: P&C TRANSMITTAL FORM (137 WI-Commercial Auto) P&C TRANSMITTAL FORM (137 WI-Commercial Auto) P&C TRANSMITTAL FORM (137 WI-Commercial Auto).pdf Filed PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

11 SERFF Tracking #: ACPC State Tracking #: Company Tracking #: ACORD 137 WI (2014/12) COMMERCIAL AUTO 2... State: Wisconsin Filing Company: ACORD Corporation TOI/Sub-TOI: 20.0 Commercial Auto/ Business Auto Product Name: ACORD 137 WI (2014/12) Commercial Auto Project Name/Number: ACORD 137 WI (2014/12) Commercial Auto /ACORD 137 WI (2014/12) Commercial Auto Status Date: 01/15/2014 Satisfied - Item: WISCONSIN FORMS LIST Comments: WISCONSIN FORMS LIST Attachment(s): WISCONSIN FORMS LIST pdf Item Status: Filed Status Date: 01/15/2014 Satisfied - Item: forms_index Comments: forms_index Attachment(s): forms_index pdf Item Status: Filed Status Date: 01/15/2014 Satisfied - Item: ACORD 137 WI (2014/12) Explanation of Changes Comments: ACORD 137 WI (2014/12) Explanation of Changes Attachment(s): 137 WI ( ).pdf Item Status: Filed Status Date: 01/15/2014 PDF Pipeline for SERFF Tracking Number ACPC Generated 02/07/ :31 AM

12 Ins 6.05 WISCONSIN ADMINISTRATIVE CODE Unofficial Text (See Printed Volume). Current through date and Register shown on Title Page. 166 Ins 6.05 Appendix A CERTIFICATE OF COMPLIANCE AND READABILITY I, Monique Hesseling (name), an officer of (company ACORD Corporation name), hereby certify that I have authority to bind and obligate the company by filing this (these) form(s). I further certify that, to the best of my information, knowledge and belief: 1. The accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance; 2. The form(s) does (do) not contain any inconsistent, ambiguous, or misleading clauses; 3. The form(s) does (do) not contain specification or conditions that unreasonably or deceptively limit the risk purported to be assumed in the general coverage of the policy form(s); 4. The only variations from a form currently on file with the commissioner of insurance and the only unconventional policy provisions are clearly marked or otherwise indicated pages of the attached form(s) or in an attachment; and 5. The attached form(s) is (are) in final printed format or typed facsimile and is (are) as will be offered for issuance or delivery in Wisconsin after approval by the Commissioner of Insurance, except for hypothetical data and other appropriate variable material. 6. If this form is a consumer insurance policy, the text of the form(s) meet(s) the minimum reading ease score or, if authorized by the commissioner, the score is lower than the minimum required by s. Ins 6.07 (4) (a) 1., Wis. Adm. Code. Product used to determine the Flesch score:. I understand that the commissioner of insurance will rely on this certification regarding the forms filed, and should it be determined that the policy form(s) does(do) not comply with the applicable laws, regulations, filing requirements and product standards or that this certification is materially false or incorrect, appropriate corrective and disciplinary action, including retroactive disapproval, as authorized by law, may be taken by the commissioner against the company and the officer completing this certification. Monique Hesseling Digitally signed by Monique Hesseling =mhesseling@acord.org, c=us (signature) Vice President, Standards (title) 01/15/2014 (date) Individual responsible for this filing: DN: cn=monique Hesseling, o=vice President, Standards, ou=standards, Date: :02:20-05'00' Name: Jean Carlos Jean Carlos Title: Filing Analyst Address: One Blue Hill Plaza, 15th Floor, Pearl River, NY Phone Number: Date: 01/15/2014 Register, January, 2011, No. 661

13 January 15, 2014 Ms. Catherine Otis Bureau of Market Regulation Wisconsin Office of the Commissioner of Insurance P.O. Box #7873 Madison, WI RE: Rate Service Organization Forms Filing ACORD Forms Filing (Commercial Auto) ACORD 137 WI (2014/12) Wisconsin Commercial Auto Dear Ms. Otis: As a rate service organization, we hereby make a form filing on behalf of ACORD s affiliated companies. Attached are the following: 1. ACORD Cover Letter 2. Property and Casualty Transmittal Document PC TD-1 3. Form Filing Schedule PC FFS-1 4. ACORD Certificate of Compliance 5. WI Certificate of Compliance and Readability 6. Certificate of Readability 7. Explanation of Changes/Use 8. ACORD Application that is being filed (Attached to Forms Schedule) Please do not hesitate to contact me at or cbelen@acord.org if I can answer any questions about this submission. We look forward to working with you on this filing. Sincerely, New York One Blue Hill Plaza 15 th Floor Pearl River, New York USA Tel Fax Carmen M. Belen, CCP, CPCU, AINS, ARM, AIS Senior Regulatory Analyst London London Underwriting Centre 3 Minster Court Mincing Lane London EC3R 7DD United Kingdom Tel +44 (0) Fax +44 (0)

14 CERTIFICATE OF COMPLIANCE ACORD Corporation Filing No This is to certify that the form included in this filing is in compliance with Wisconsin insurance laws and rules. Kori M. Johanson Chief Compliance Officer & Regulatory Counsel January 15, 2014 New York One Blue Hill Plaza 15 th Floor Pearl River, New York USA Tel Fax London London Underwriting Centre 3 Minster Court Mincing Lane London EC3R 7DD United Kingdom Tel +44 (0) Fax +44 (0)

15 CERTIFICATE OF READABILTY I hereby certify that all the forms in this filing meet the minimum standards set forth in Wisconsin Statutes. Kori M. Johanson Chief Compliance Officer & Regulatory Counsel January 15, 2014 New York One Blue Hill Plaza 15 th Floor Pearl River, New York USA Tel Fax London London Underwriting Centre 3 Minster Court Mincing Lane London EC3R 7DD United Kingdom Tel +44 (0) Fax +44 (0)

16 Effective January 1, 2009 Property & Casualty Transmittal Document Reset Form 1. Reserved for Insurance Dept. Use Only 2. Insurance Department Use only a. Date the filing is received: b. Analyst: c. Disposition: d. Date of disposition of the filing: e. Effective date of filing: New Business Renewal Business f. State Filing #: g. SERFF Filing #: h. Subject Codes 3. Group Name Group NAIC # 4. Company Name(s) Domicile NAIC # FEIN # State # ACORD Corporation NY New York 5. Company Tracking Number ACORD (137 Wi- Commercial Auto) Contact Info of Filer(s) or Corporate Officer(s) [include toll-free number] 6. Name and address Title Telephone #s FAX # Jean Carlos ACORD Corporation One Blue Hill Plaza, 15thFloor PO Box 1529 Pearl River, NY Signature of authorized filer 8. Please print name of authorized filer Jean Carlos Filing information (see General Instructions for descriptions of these fields) 9. Type of Insurance (TOI) 10. Sub-Type of Insurance (Sub-TOI) 20.0 Commercial Auto Business Auto 11. State Specific Product code(s)(if applicable)[see State Specific Requirements] 12. Company Program Title (Marketing title) 13. Filing Type [ ] Rate/Loss Cost [ ] Rules [ ] Rates/Rules [ ] Forms [ ] Combination Rates/Rules/Forms [ ] Withdrawal[ ] Other (give description) 14. Effective Date(s) Requested New: Renewal: 12/01/ Reference Filing? [ ] Yes [ ] No 16. Reference Organization (if applicable) 17. Reference Organization # & Title 18. Company s Date of Filing 01/15/ Status of filing in domicile [ ] Not Filed [ ] Pending [ ] Authorized [ ] Disapproved PC TD-1 pg 1 of 2 Forms Filing Analyst jcarlos@acord.org Jean Carlos Digitally signed by Jean Carlos DN: cn=jean Carlos, o=acord, ou, =jcarlos@acord.org, c=us Date: :56:52-05'00'

17 Property & Casualty Transmittal Document 20. This filing transmittal is part of Company Tracking # ACORD (137 WI-Commercial Auto) 21. Filing Description [This area can be used in lieu of a cover letter or filing memorandum and is free-form text] January 15, 2014 Ms. Catherine Otis Bureau of Market Regulation Wisconsin Office of the Commissioner of Insurance P.O. Box #7873 Madison, WI RE: Rate Service Organization Forms Filing ACORD Forms Filing (Commercial Auto) ACORD 137 WI (2014/12) Wisconsin Commercial Auto Dear Ms. Otis: As a rate service organization, we hereby make a form filing on behalf of ACORD s affiliated companies. Attached are the following: 1. ACORD Cover Letter 2. Property and Casualty Transmittal Document PC TD-1 3. Form Filing Schedule PC FFS-1 4. ACORD Certificate of Compliance 5. WI Certificate of Compliance and Readability 6. Certificate of Readability 7. Explanation of Changes/Use 8. ACORD Application that is being filed (Attached to Forms Schedule) Please do not hesitate to contact me at or cbelen@acord.org if I can answer any questions about this submission. We look forward to working with you on this filing. Sincerely, Carmen M. Belen, CCP, CPCU, AINS, ARM, AIS Senior Regulatory Analyst View Complete Filing Description 22. Filing Fees (Filer must provide check # and fee amount if applicable) [If a state requires you to show how you calculated your filing fees, place that calculation below] Check #: Amount: Refer to each state s checklist for additional state specific requirements or instructions on calculating fees. ***Refer to the each state s checklist for additional state specific requirements (i.e. # of additional copies required, other state specific forms, etc.) PC TD-1 pg 2 of National Association of Insurance Commissioners

18 Effective January 1, 2009 FORM FILING SCHEDULE (This form must be provided ONLY when making a filing that includes forms) (Do not refer to the body of the filing for the forms listing, unless allowed by state.) 1. This filing transmittal is part of Company Tracking # This filing corresponds to rate/rule filing number (Company tracking number of rate/rule filing, if applicable) Form Name /Description/Synopsis Wisconsin Personal Auto Application Form # Include edition date ACORD 137 WI (2014/12) ACORD (137 WI-Commercial Auto) Replacement Or withdrawn? [ ] New [ ] Replacement [ ] Withdrawn If replacement, give form # it replaces ACORD 137 WI (2011/12) Previous state filing number, if required by state ACPC [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn [ ] New [ ] Replacement [ ] Withdrawn PC FFS National Association of Insurance Commissioners

19 Effective January 1, 2009 RATE/RULE FILING SCHEDULE (This form must be provided ONLY when making a filing that includes rate-related items such as Rate; Rule; Rate & Rule; Reference; Loss Cost; Loss Cost & Rule or Rate, etc.) (Do not refer to the body of the filing for the component/exhibit listing, unless allowed by state.) 1. This filing transmittal is part of Company Tracking # 2. This filing corresponds to form filing number (Company tracking number of form filing, if applicable) Rate Increase Rate Decrease Rate Neutral (0%) 3. Filing Method (Prior Approval, File & Use, Flex Band, etc.) 4a. Rate Change by Company (As Proposed) Company Name Overall % Indicated Change (when applicable) Overall % Rate Impact Written premium change for this program # of policyholders affected for this program Written premium for this program Maximum % Change (where required) Minimum % Change (where required) 4b. Rate Change by Company (As Accepted) For State Use Only Company Name Overall % Indicated Change (when applicable) Overall % Rate Impact Written premium change for this program # of policyholders affected for this program Written premium for this program Maximum % Change Minimum % Change 5. Overall Rate Information (Complete for Multiple Company Filings only) COMPANY USE STATE USE 5a Overall percentage rate indication (when applicable) 5b Overall percentage rate impact for this filing 5c Effect of Rate Filing Written premium change for this program 5d Effect of Rate Filing Number of policyholders affected 6. Overall percentage of last rate revision 7. Effective Date of last rate revision Filing Method of Last filing 8. (Prior Approval, File & Use, Flex Band, etc.) 9. Rule # or Page # Submitted for Review Replacement or withdrawn? Previous state filing number, if required by state 01 [ ] New [ ] Replacement [ ] Withdrawn 02 [ ] New [ ] Replacement [ ] Withdrawn 03 [ ] New [ ] Replacement [ ] Withdrawn PC RRFS National Association of Insurance Commissioners

20 WISCONSIN LIST OF FORMS INCLUDED IN THIS FILING FORMS ACORD 137 WI (2014/12) Wisconsin Commercial Auto 1/15/2014

21 Please provide the information below to avoid delay in shipment. ACORD Forms Index Agency/Company Name: Contact Name: Street Address: City: Telephone: Fax: Web Site: State: ACORD Account #: Address: Zip: /01 Property Loss Notice All packages contain 100 forms - Please specify number of packages required COUNTRYWIDE P&C FORMS # Current Future Title Quantity # Current Future Title Quantity /03 Personal Policy Change Request (Except Auto) /01 Automobile Loss Notice /03 Personal Auto Policy Change Request /01 General Liability Notice of Occur/Claim /10 Mobile Home Supplement / /01 Aircraft Loss Notice 2/95 2/95 2/ /09 Workers Compensation - First Report of Injury or Illness /05 Aviation Witness / Passenger Schedule /05 Aviation Injured Schedule Auto Accident Information Form Exchange of Information Form Witness Card /12 Certificate of Aviation Liability Insurance /12 Certificate of Aircraft Insurance /04 Intermodal Interchange Certificate of Insurance 2010/ / /01 Vehicle or Equipment Certificate of Insurance Certificate of Property Insurance Certificate of Liability Insurance /07 Solid Fuel Questionnaire - Supplement to Residential Section / /09 Insurance Binder 76 9/93 Binder Log Residence Based Business Supplement to Residential Section /09 Homeowner Application /09 Personal Inland Marine Application 2013/ /09 Watercraft Application Personal Umbrella Application /09 Dwelling Fire Application /09 Mobile Home Application 2013/ /02 Residential Section Personal Insurance Application - Applicant Information Section /01 Policy Certification Log /10 Good Student Driver Training /12 Evidence of Property Insurance /03 Medical Statement / /01 Evidence of Commercial Property Insurance /03 Young Driver Questionnaire 29 Evidence of Flood Insurance / /01 Certificate of Garage Insurance / /01 Certificate of Marine / Energy Insurance / / / /01 Cancellation Request / Policy Release Agent/Broker of Record Change Statement of No Loss Notice of Insurance Information Practices (Privacy) /07 Residential Property Replacement Cost /02 Accidents / Convictions Schedule /01 Additional Remarks Schedule /03 Personal Auto Application Schedule - Additional Resident and Driver Information Section /06 Apartment Building Supplement /04 Vacant Building Supplement 2013/ / /04 Commercial Insurance Application Applicant Information Section Commercial General Liability Section /04 Additional Interest Schedule /03 Business Auto Section /02 Automobile Insurance ID Card /04 Garage and Dealers Section 50 WM 2007/03 Automobile Insurance ID Card (with Watermark) /11 Vehicle Schedule 54 1/97 Financial Responsibility Form /09 Workers Compensation Application 57 1/97 Financial Responsibility Form - Cancellation /12 Umbrella Section /11 Notice of Cancellation or Termination of Policy US 62 US 2010/ / / /09 Fraud Statements 64 US 2008/ /05 Flood Insurance Selection / Rejection Insurance Supplement - Notice - Offer of Terrorism Coverage Insurance Supplement - Standard Fire Policy Only Notice - Offer of Terrorism Coverage Insurance Supplement - Workers' Compensation Only Notice - Offer of Terrorism Coverage Personal Insurance Supplement - Extraordinary Life Circumstances /08 Electronic Delivery Supplement / / / / /10 Truckers / Motor Carriers Section /09 Accounts Receivable / Valuable Papers /09 Equipment Floater Section Workers Compensation Insurance Plan - Assigned Risk Section Statement/Schedule of Values Property Section Crime Section /09 Transportation Section /09 Glass And Sign Supplement Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014) ACORD Member Services - Phone: (845) , Option 2 - Fax: (845) All forms are available for download on the ACORD web site ( ACORD Forms Index (rev ) Page 1 of 11

22 ACORD Forms Index All packages contain 100 forms - Please specify number of packages required COUNTRYWIDE P&C FORMS - continued # Current Future Title Quantity # Current Future Title Quantity /09 Installation / Builder's Risk Section /06 Aircraft Change Request /09 Electronic Data Processing Section /11 Pilot Experience Change Request /09 Dealers Section /06 Hangar Change Request 155 BM 2004/12 Boiler & Machinery Section Watermark Paper - 20 # ID Card Stock (4-part perforation) /03 Schedule of Insurance 360 Watermark Paper - 32 # ID Card Stock (4-part perforation) /10 Business Owners Section 370 Watermark Paper - 32 # ID Card Stock (non-perforated) /06 Commercial Auto Driver Information Schedule /09 Agriculture Application /04 Commercial Policy Change Request /03 Agriculture Property Section 180 1/97 Errors and Omissions Section - Electronic Data Processors, etc /09 Agriculture Property Section Scheduled / Unscheduled Personal Property /09 Restaurant/Tavern Supplement /09 Agriculture Liability Section /10 Contractors Supplement 187 3/98 Professional Liability Supplement /06 Employment Related Practices Liability Section /09 Supplemental Property Application /09 Open Cargo Section /03 Truckers / Motor Carrier Supplement /96 Design Professional's Individual Property Survey /09 Medical Professional Liability Insurance Application 199 1/99 Application Supplement - Undertaking 200 3/93 Producer Account 201 3/93 Producer Account Discrepancy Notice /09 Yacht Section 225 1/98 Policyholder's Report 226 3/93 Statement of Premium Adjustment /05 Aviation Insurance Binder / / / / / / /04 Premium Payment Supplement 2002/01 Railroad Protective Liability Supplement 2011/ / / / / /10 Agriculture Premises Diagram Agriculture Supplement - Unscheduled Farm Personal Property Inventory Form Livestock Mortality Section Equine Liability Supplement Small Farm / Ranch Application Surety Report of Execution Hotel / Motel Supplement Liquor Liability Section Directors & Officers Liability Section P&C Agency Appointment Form Business Income / Extra Expense / Rental Value Supplement to Property Section Value Reporting Information Supplement to Property Section /05 Aircraft Insurance Binder /02 Agency Questionnaire /10 Personal Inland Marine Section /03 Request for Proof of Property Insurance /03 Watercraft Section /02 International Liability Exposure Supplement /09 Personal Umbrella Application Section /06 International Property Exposure Supplement National Flood Insurance Program Flood Insurance Application NFIP - Flood Insurance General Change Endorsement NFIP - Flood Insurance Preferred Risk Policy Application /08 P&C Producer Appointment Form - Appointment Section 2007/08 P&C Producer Appointment Form - Background Questions 2010/08 P&C Producer Appointment Form - Additional Appointment or Termination 304 NFIP - Flood Insurance Cancellation / Nullification /01 Producer Information Form (PIF) /02 NFIP - Credit Card Payment Form /07 Driver Work / School Address Information Supplement / /04 NFIP - Rating Information and Elevated Building Determination Form NFIP - Floodproofing Certificate for Non-Residential Structures / /09 Additional Premises Information Schedule Professional / Specialty Insurance Application - For Use in Management, Executive & Professional Lines Applicant Section /04 NFIP - Residential Basement Floodproofing Certificate /01 Employment Practices Liability Insurance Section /09 Aviation Insurance Application - Applicant Information Section /09 Fiduciary Liability Coverage Section /04 Airport Property Supplement /05 Forms and Endorsements Schedule /04 Airport and FBO Liability Section /11 Property Insurance Card /04 Private Hangar Liability Section /01 Professional / Specialty Insurance Notice of Incident / Claim /06 Aviation Products Liability /09 Miscellaneous E&O Section /04 Aircraft Section /07 Lawyers Professional Liability Section /11 Pilot Experience /09 Cyber and Privacy Coverage Section /04 Hangar Schedule /12 Accountants Professional Liability Section / /05 Aircraft Schedule 2009/06 Aviation Policy Change Request Applicant Information Section Airport Property Change Request / / /06 Airport and FBO Liability Change Request Private Hangar Liability Change Request 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 2014/01 for use on or after 1/1/2014) ACORD Member Services - Phone: (845) , Option 2 - Fax: (845) All forms are available for download on the ACORD web site ( ACORD Forms Index (rev ) Page 2 of 11

23 ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS # Current Future Title Quantity # Current Future Title Quantity 138 AL 61 AK 62 AK 90 AK 137 AK 138 AK 171 AK 290 AK 50 AR 90 AR 137 AR 138 AR 38 AZ 2003/10 Arizona Notice of Information Practices (Privacy) 61 AZ 2001/02 Arizona Auto Supplement UM/UIM Coverage Selection 90 AZ 137 AZ 138 AZ 2007/10 67 AR 2000/02 Arizona 50 AZ 2012/08 Arizona Insurance Identification Card 2012/ / / AZ 2010/11 Arkansas Arkansas Proof of Insurance Card 61 AR 2010/04 Arkansas Auto Supplement UM/UIM Coverage 2010/06 Arkansas Personal Auto Application 2012/06 Alaska 7/97 Alaska Auto Supplement - UM/UIM Coverage Selection 2/98 Alaska Auto Supplement - Exclusion of Named Drivers 2011/12 Alaska Personal Auto Application 2011/ /04 Alabama 50 AL 2007/10 Alabama Insurance Identification Card 62 AL 5/98 Alabama Insurance Application Supplement 90 AL 137 AL 290 AL 2013/ / / /02 62 AR 2013/09 Arkansas Personal Umbrella Supplement Arkansas Property Supplement - Declination of Residential Earthquake Coverage Arkansas Commercial Auto Arkansas Garage and Dealers 290 AR 2010/06 Arkansas Personal Auto Application Section 838 AR 2013/12 61 CA 64 CA 65 CA 66 CA 67 CA 68 CA 90 CA 137 CA 138 CA 177 CA Alaska Commercial Auto Alaska Garage and Dealers 6/98 Alaska Petition For Executive Officer Waiver 2011/12 Alaska Personal Auto Application Section 2011/ / /03 Alabama Personal Auto Application Alabama Commercial Auto Alabama Garage and Dealers Alabama Personal Automobile Application Section Arizona Personal Auto Application Arizona Commercial Auto Arizona Garage and Dealers Arizona 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 854 CA 855 CA 2008/ / / / / / /04 California Auto Supplement - Mandatory UM Bodily Injury / Property Damage Coverage Offer California Insurance Supplement - Agency Language California Insurance Supplement - Race, National Origin, Gender California Offer of Earthquake Coverage California Residential Property Insurance Disclosure California Scheduled Personal Property Loss Computation Disclosure California Personal Auto Application California Commercial Auto California Garage and Dealers California Auto Body Repair Consumer Bill of Rights 290 CA 2010/12 California Personal Auto Application Section 2013/ /07 Arkansas Accountants Professional Liability Section 69 CA California Insurance Supplement California FAIR Plan Property Insurance - Application for Dwelling Insurance California FAIR Plan Property Insurance - Application for Commercial Insurance 856 CA 857 CA 61 CO 90 CO 137 CO 138 CO 171 CO 61 CT 66 CT 90 CT 137 CT 138 CT 171 CT 172 CT 173 CT 38 DE 50 WM 61 DE 64 DE 65 PA / DE / WV 90 DE 171 DE 2006/01 Delaware FAIR Plan Supplementary Questionnaire Delaware Personal Auto Application 137 DE 2013/12 Delaware Commercial Auto 138 DE 2008/ / / /05 Delaware Personal Insurance Supplement Notice of Information Practices (Privacy) Automobile Insurance ID Card (with Watermark) DE Auto Supplement, DE Motorist's Protection Act Required Statement to Policyholders 62 DE 2004/10 DE Auto Supplement, PIP Deductible Options 290 DE 2010/ / / / / /08 Connecticut 50 CT 2009/01 Connecticut Insurance Identification Card 62 CT 2006/ / / / /04 Colorado 50 CO 2007/03 Colorado Insurance Identification Card 64 CO 65 CO 66 CO 67 CO 68 CO 2011/ / / / / / / / / /02 California (continued) 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 Colorado Auto Supplement - Summary of Coverages Colorado Auto Supplement - Colorado Offer of Medical Payments Coverage Colorado Personal Property Supplement - Summary of Coverage Renters Policy Colorado Personal Property Supplement - Summary of Coverage Condominium Policy Colorado Personal Property Supplement - Summary of Coverage Dwelling Fire Policy Colorado Personal Property Supplement - Summary of Coverage Homeowners Policy Colorado Personal Automobile Application Colorado Commercial Auto Colorado Garage and Dealers Colorado Rejection of Coverage by Corporate Officers 290 CO 2010/08 Colorado Personal Automobile Application Section Connecticut Auto Supplement - UM Coverage Connecticut Personal Insurance Supplement - Summary of Consumer Protections Connecticut FAIR Plan Application for Property / Liability Insurance Connecticut Personal Auto Application Connecticut Commercial Auto Connecticut Garage and Dealers 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 Connecticut Workers' Comp. Comm. - Coverage Election by Employees who are Members of a Partnership Connecticut Workers' Comp. Comm. - Coverage Election by Sole Proprietor or Single-Member LLC 290 CT 2011/01 Connecticut Personal Automobile Application Section Insurance Placement Facility of Delaware Basic Property Insurance Application 67 DE 2012/01 Delaware Insurance Supplement 2013/12 California FAIR Plan Property Insurance - Application for Businessowners (BOP) Insurance Delaware Garage and Dealers Delaware Executive Officer(s) Exclusion Delaware 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 2014/01 for use on or after 1/1/2014) 69 CO 2013/ / /01 Colorado Personal Property Supplement - Homeowner's Insurance Replacement-Cost Applicants ACORD Member Services - Phone: (845) , Option 2 - Fax: (845) All forms are available for download on the ACORD web site ( ACORD Forms Index (rev ) Page 3 of 11

24 ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS - continued # Current Future Title Quantity # Current Future Title Quantity 62 DC 64 DC 66 DC 67 DC 68 DC 90 DC 137 DC 138 DC 290 DC 50 FL 2013/ / / / / / /07 District of Columbia District of Columbia Personal Property Supplement, Statement Regarding Flood Insurance Application to District of Columbia Property Insurance Facility for Basic Property Insurance District of Columbia Property Insurance Facility - Essential Homeowners Ins. Inspection and Placement Application p. 1 District of Columbia Property Ins. Facility - Essential Homeowners Ins. Inspection and Placement Application p. 2 District of Columbia Personal Property Supplement, Statement Regarding Sewer-line Backup Insurance District of Columbia Personal Auto Application District of Columbia Commercial Auto District of Columbia Garage and Dealers District of Columbia Personal Auto Application Section Florida Florida Personal Auto ID Card 50 HI 60 HI 90 HI 94 HI 137 HI 138 HI 290 HI 137 ID 138 ID 2008/01 Hawaii Auto ID Card Hawaii 2010/07 Hawaii Auto Supplement - UM/UIM/PIP 2011/12 Hawaii Personal Auto Application 2001/03 Hawaii Vehicle Inspection Report Supplement 2011/ / /12 Hawaii Commercial Auto Hawaii Garage and Dealers Hawaii Personal Auto Application Section Idaho 50 ID 2007/10 State of Idaho Liability Insurance Identification Card 61 ID 2009/01 90 ID 2010/08 Idaho Personal Auto Application 2011/ /02 Idaho Auto Supplement - Idaho Uninsured Motorist and Underinsured Motorist Disclosure Statement Idaho Commercial Auto Idaho Garage and Dealers 51 FL 61 FL 62 FL 64 FL 65 FL 2007/08 66 FL 67 FL 7/94 70 FL 90 FL 130 FL 133 FL 134 FL 137 FL 138 FL 2009/ / / / / / / FL 2011/10 Florida Insurance Supplement Credit Report Disclosure Information Florida Homeowners Supplement Florida Personal Auto Application 2002/07 Florida Workers Compensation Application 2013/03 Florida Workers Comp. Addendum to ACORD 130 FL 2010/ / / /01 Florida Commercial Auto ID Card Florida Auto Supplement - Rejection/Election of UM Coverage Florida Auto Supplement - Personal Injury Protection Options Florida Auto Supplement - Notice to Policyholders - Florida Notification of Availability of Uninsured Motorist Coverage Florida Residential Property Supplement Florida Property Supplement Uniform Mitigation Verification Inspection Form Florida Commercial Insurance Application Applicant Information Section Florida Workers Comp. Instructions for Completing ACORD 130 FL and 133 FL Florida Commercial Auto Florida Garage and Dealers 290 ID 2010/08 Idaho Personal Automobile Application Section 50 IL 2007/03 61 IL 2003/03 62 IL /07 90 IL 137 IL 138 IL 171 IL IN 2007/08 67 IL 2012/ / / / /06 Indiana 50 IN 2007/11 Indiana Insurance Identification Card 2011/ /08 Illinois Illinois Insurance Identification Card Illinois Auto Supplement - UM/UIM Illinois Property Supplement - Notice of Availability of Earthquake Insurance Mine Subsidence Property Insurance Supplement Illinois, Indiana, Kentucky, West Virginia Illinois Insurance Supplement - Civil Union Disclosure Illinois Personal Auto Application Illinois Commercial Auto Illinois Garage and Dealers Illinois FAIR Plan Application for Commercial Property Insurance 290 IL 2012/03 Illinois Personal Auto Application Section Mine Subsidence Property Insurance Supplement Illinois, Indiana, Kentucky, West Virginia Indiana Personal Auto Application 171 FL 2004/04 Florida Notice of Election of Coverage 137 IN 2011/07 Indiana Commercial Auto 172 FL 2007/08 Florida Revocation of Election to be Exempt 138 IN 2012/02 Indiana Garage and Dealers 174 FL 2007/08 Florida Revocation of Election of Coverage 175 FL 220 FL 221 FL 90 GA Georgia 50 GA 2008/11 Georgia Insurance Policy Information Card 51 GA 2005/01 Georgia Fleet Policy Information Card 64 GA 3/97 Florida Workers Compensation Monthly Change Sheet 2012/ / FL 2011/ FL 863 FL 2013/ / / /08 Citizens Property Insurance Corporation Commercial - Residential Wind Only Citizens Property Ins Corp, Wind Only - Supplemental Application Schedule Commercial and Commercial - Residential Florida Commercial Auto Addendum Florida Commercial Auto Addendum Florida Commercial Auto Addendum Georgia Auto Supplement - Georgia Auto Disclosure Form, Notice to Policyholders, Uninsured Motorist Coverage Selection Georgia Personal Auto Application 290 IN 2010/08 Indiana Personal Auto Application Section 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 67 IA 90 IA 137 IA 138 IA 2006/ /07 Iowa Personal Insurance Supplement Disclosure Use of Claims History 2011/01 Iowa Personal Auto Application 2011/ /05 Iowa Personal Insurance Supplement Extraordinary Life Circumstances Disclosure Iowa Commercial Auto Iowa Garage and Dealers 290 IA 2011/01 Iowa Personal Automobile Application Section 137 GA 138 GA 171 GA 2011/ / /05 Georgia Commercial Auto Georgia Garage and Dealers Georgia State Board of Workers' Compensation - Notice of Election or Rejection of Workers' Compensation Coverage 290 GA 2010/08 Georgia 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 2014/01 for use on or after 1/1/2014) ACORD Member Services - Phone: (845) , Option 2 - Fax: (845) All forms are available for download on the ACORD web site ( ACORD Forms Index (rev ) Page 4 of 11