To Access the ACORD forms on the Florida Insurance Research Library click here.

Transcription

1 The ACORD Advantage Program is accessed through the Acord site. Below is the link to the Acord Forms in the Research Library. The ACORD Advantage Program provides agents and brokers with broad based information and services that help with operations, compliance and communications, in addition to unlimited access to ACORD Forms. ACORD Advantage participation entitles you, and all employees at your location, with 12 months of access to the ACORD Advantage services and products at a flat $129 fee. Enroll Today! Already enrolled? Sign In now to access your privileges. To Access the ACORD forms on the Florida Insurance Research Library click here. Back to Main Menu Janruary 2004

2 Form # Edition Form Name /01 Property Loss Notice /11 Automobile Loss Notice /01 General Liability Notice of Occur/Claim 4 WI 2003/04 Workers Compensation - Employers 1st Rep /02 WI Employer s First Report of Injury or Disease 11 2/95 Auto Accident Information Form 12 2/95 Exchange of Information Form 13 2/95 Witness Card 18 1/98 Jewelry Appraisal & Claim Evaluation 23 1/99 Leased Auto Certificate of Insurance 24 1/95 Cerificate of Property Insurance /08 Certificate of Liability Insurance /01 Certificate Log /10 Evidence of Personal Property Insurance /10 Evidence of Commercial Property Insurance 35 1/97 Cancellation Request/Policy Release 36 1/98 Agent/Broker of Record Change 37 1/96 Statement of No Loss 38 AR 2001/08 Arkansas Notice of Information Practices 38 AZ 2003/10 Arizona Notice of Information Practices 38 CO 2001/07 Colorado Notice of Information Practices 38 MN 2002/08 Minnesota Notice of Information Practices 38 MO 2002/09 Miissouri Notice of Information Practices 38 MT 2001/01 Montana Notice of Information Practices 38 NH 2002/09 New Hampshire Notice of Information Practices 38 OR 2003/05 Oregon Notice of Information Practices /09 Notice of Information Practices for states of CA/CT/DE/GA/IL/NV/NJ/RI/VA/ WA 39 MD 2003/05 MD Supplement Notice of Intent to Use Credit History /01 Residential Property Valuation Survey 41 1/98 Residential Prop Replacement Cost Wkst /05 Residential Property Replacement Cost /04 Additional Interest 50 AR 2003/07 Arkansas Proof of Insurance Card 50 FL 3/94 FL Auto ID Card 50 HI 1/99 HI Auto ID Card 50 IA 2002/12 Iowa Financial Responsibility Card 50 KY 3/98 Commonwealth of KY Proof of Insurance (2 part) 50 LA 4/96 LA Auto ID Card Set (2 part) 50 MI 6/93 Michigan Insurance Auto ID Card 50 MO 2/98 Missouri Auto Insurance ID Card 50 MS 2001/01 Mississippi Auto Insurance ID Card 50 NV 2002/04 Nevada Insurance Identification Card 50 OK 2002/07 OK Owners Security Verification Form 50 PA 2002/08 Pennsylvania Financial Responsibility Identification Card 50 1/83 ACORD Insurance ID Card 50 TX 2003/09 Texas Liability Insurance Card 50 WM 2/95 ACORD auto ID card (w/watermark) 50 WV 3/94 WV Auto ID Card 51 OK 2002/07 OK Operators Security Verification Form 60 HI 7/99 Hawaii Auto Supplement 60 LA 4/98 Louisiana Dwelling Supplement 60 MA 2003/04 Massachusetts Property Insurance Underwriting Association for Homeowners Insurance

3 60 MT 2003/09 Montana Supplement - Refusal to Renew 60 NJ 2001/10 New Jersey Homeowners Insurance Supplement Flood Exclusion 60 NM 2003/01 New Mexico Confidential Abuse Disclosure 60 NY 8/95 New York Homeowners Supplement 60 OK 10/94 Oklahoma Auto Supplement 60 PA 2003/07 PA Unins Mot Cov Select/Reject 60 TX 2002/12 TX Auto Sup, Cons Bill Right Pers Auto 60 US 2003/01 Insurance Supplement - Offer of Terrorism Coverage 60 VA 8/94 Virginia Auto Supplement 60 WV 12/93 West Virginia Personal Auto Supplement /09 Flood Insurance Notice/Rejection 61 AK 7/97 AK Auto Supplement 61 AR 2002/03 AR Auto Sup, Unin/Under Prot 61 AZ 2001/02 AZ Auto Supplement 61 CA 7/98 CA Auto Sup, Mand Unin Motor Bl Offer 61 CO 2003/07 Colorado Auto Supplement 61 CT 1/95 CT Auto Supplement UM Coverage 61 DE 3/97a DE Auto Supplement, Unin Motorists 61 FL 2003/09 FL Auto Sup, Rejection/Election UM 61 GA 2002/12 Georgia Auto Supplement 61 IA 2002/02 IA Auto Supplement 61 IL 2003/03 IL Auto Sup, Unin/Under Motorist 61 LA 2001/05 Louisiana Homeowners Supplement 61 MA 2003/04 Massachusetts Property Insurance Underwriting Association Instruct. for Completing Homeowners App ACORD 60 MA 61 MD 2003/09 Maryland Personal Auto Supplement - Notice UM 61 MS 2002/09 Mississippi Auto Supplement Non-Stacking UM Insurance 61 NC 8/97 North Carolina Auto Supplement 61 NJ 2000/09 NJ Auto Ins. Buyer s Guide 61 NV 2002/12 NV Auto Sup, Mand Offr MedPay & Un 61 NY 3/94 New York Auto Supplement 61 OK 3/94 Oklahoma Auto Supplement 61 OR 3/94 Oregon Auto Supplement 61 PA 2003/07 PA Auto Supp, 1st Party Benefits Cov 61 RI 4/95 RI Auto Supp, Uninsured Motorists 61 SC 2003/02 SC Auto Supplement, Offer of Optional UM/ UIM Coverage. 61 UT 2001/02 Utah Auto Supplement UM/UIM Coverage Selection 61 WI 5/96 Wisconsin Auto Supplement 61 WV 2000/10 WV Uninsure/Underins Motor - Split 62 AK 2/98 Alaska Auto Supplement 62 AL 5/98 Alabama Insurance Supplement 62 AZ 2003/05 Arizona Auto Supplement (Spanish Version) UM/UIM Coverage Selection Form 62 CA 2001/05 California Auto Supplement 62 CO 2/97 CO Personal Property Supplement 62 IA 2/98 Iowa Auto Supplement 62 IL 2006/04 Illinois Property Supplement Notice of Availability of Earthquake Insurance 62 LA 4/98 Louisiana Commercial Property Supplement 62 MD 1/98 Maryland Commercial Auto Supplement 62 MI 2000/01 MI Collision Insurance Options Notice 62 MN 2000/01 Minnesota Auto Supplement 62 NC 9/97 N. Carolina Fair & Beach Plan Coverage 62 NH 2000/08 NH Statement of Residency or Exemption 62 NJ 2000/09 NJ Auto Supp Basic Policy Coverage 62 NV 2001/05 Nevada Umbrella Supplement 62 NY 2000/02 NY For Dwelling Insurance 62 PA 203/07 Pennsylvania Auto Supplement - UIM Coverage Sel/Reject

4 62 SC 2/96 South Carolina Commercial Auto Supplemt 62 TX 2002/12 Texas Auto Supplement (Spanish Version) 62 US 2003/01 Insurance Supplement - Standard Fire Policy Only - Offer of Terrorism Coverage 62 VA 6/97 Virginia Property Supplement 62 WA 2002/03 Washington Auto Supplement 62 WV 2000/10 WV Uninsure/Underins Motor - Single 63 CO 1/97 CO Supplement 63 HI 9/98 Hawaii Supplement 63 OH 9/93 Ohio Fraud Statement 63 OK 10/97 Oklahoma Fraud Statement 63 UT 9/93 Utah Fraud Statement /10 General Fraud Statement 64 CA 1/95 California Insurance Supplement 64 DC 2002/02 to DC Property Insurance Facility (p. 1 of 2) 64 DE 2000/05 Insurance Placement Facility of Delaware Basic Property Insurance 64 IA 2/98 Iowa Auto Supplement 64 LA 2001/05 Louisiana Homeowners Supplement 64 MA 2/97 MA Residential Prop Liability Supp: Lead Poisoning Liability 64 MD 8/98 Maryland Essential Property Inspection 64 MI 2000/10 MI Basic Property Insurance Assn Ins. 64 NC 2001/02 North Carolina Property Supplement Flood Insurance Notice 64 NJ 2000/09 NJ Auto Supp Standard Policy Coverage 64 NY 2003/01 New York Auto Supplement 64 PA 2000/01 Insurance Placement Facility of Pennsylvania Basic Property Insurance 64 RI 2003/04 RI Joint Ins Association - for Homeowners Ins. 64 TX 2003/04 TX Windstorm Ins. Assn. 64 US 2003/02 Insurance Supplement - Workers Compensation Only 64 VA 2000/08 VA Property Supplement Flood Ins. Exclusion 64 WV 2000/10 WV Essential Property Ins Assn Basic Property Ins App 65 CA 1/95 California Insurance Supplement 65 DC 2001/06 to DC Property Insurance Facility (p. 2 of 2) 65 IA 2000/07 Iowa Auto Supplement - (Aftermarket Crash Parts) 65 LA 2001/02 Louisiana Homeowners Supplement 65 MA 2003/04 Massachusetts Property Insurance Underwriting Association for Dwelling Fire Insurance Inspection and Placement 65 MD 2001/06 to MD Joint Insurance Association (p. 1 of 2) 65 MN 3/94 Minnesota Guaranty Association 65 NJ 2003/02 New Jersey Property Insurance Supplement 65 NY 2003/01 New York Auto Supplement - Spousal Liability Coverage 65 PA/ DE/ WV 2000/01 FAIR Plan Supplementary Questionnaire 65 RI 2003/04 RI Joint Ins Association - Instructions for Homeowners App 65 WV 2001/08 WV Umbrella Liability Supplement Important Notice 66 CA 2/98 California Offer of Earthquake Coverage 66 CT 2001/08 CT FAIR Plan for Property/ Lability Insurance 66 FL 2001/08 FL Insurance Supplement 66 IA 2006/07 Iowa Personal Insurance Supplement Disclosure Use of Claims History 66 LA 4/98 Louisiana Dwelling Supplement

5 66 MA 2003/04 Massachusetts Property Insurance Underwriting Association Inspection Notice, Credit Reporting Notice and Instructions for Completing Dwelling Fire ACORD 65 MA 66 MD 2001/06 to MD Joint Insurance Association (p. 2 of 2) 66 MN 2003/03 Minnesota Fair Plan Homeowners 66 NC 8/97 North Carolina Insurance Supplement 66 RI 2003/04 Rhode Island Joint Reinsurance Association - for Dwelling Fire Insurance Inspection and Placement 66 US 2003/02 Insurance Supplement - Commercial Auto Only - AK, CT, HI, KS, KY, NJ, NY, OR 66 UT 6/94 Utah Insurance Supplement 66 VT 2003/06 VT Insurance Sup, Fair Crdt Reprtng Act 66 WV 2001/08 WV Umbrella Liability Supplement Uninsured/Underinsured Motorists Coverage (Split Limits) 67 AR 2000/02 Arkansas Declination of Res. Earthquake Coverage 67 CA 11/94 California Residential Property Ins Dis 67 FL 7/94 Florida Homeowners Supplement 67 LA 5/98 Certification of Mobile Home Tie Downs 67 MA 2003/04 Massachusetts Property Insurance Underwriting Association for Commercial Fire Insurance Inspection and Placement 67 MD 2003/09 Maryland Personal Auto Supplement - Notice PIP 67 MN 2003/03 Minnesota Fair Plan Dwelling Fire 67 MO 2003/11 Missouri FAIR Plan Insurance 67 NJ 2002/07 New Jersey Underwriting Insurance Association Dwelling Fire 67 NY 2000/08 Instructions/Completion of ACORD 62 NY 67 OH 1/94a Ohio Mine Subsidence 67 RI 2003/04 Rhode Island Joint Reinsurance Association - Inspection Notice, Credit Reporting Notice and Instructions for Completing Dwelling Fire ACORD 66 RI 67 TX 2002/12 Texas Homeowners and Personal Property 67 UT 10/94 UT Auto, PIP Cov, Waiv Loss Income 67 VA 2000/11 Virginia Property Insurance Assoc /07 IL, IN, KY, WV Mine Subsidence 68 CA 2001/03 CA Scheduled Personal Property - Loss Computation Disclosure 68 FL 2003/08 Citizens Property Insurance Corporation, Residential - Dwelling Wind Only 68 IL 2003/07 IL FAIR Plan Supp App for Homeowners/ Dwelling (Part 2 of 2) 68 LA 4/98 Louisiana Plan Services App. for Ins. 68 MA 2003/04 Massachusetts Property Insurance Underwriting Association Inspection Notice, Credit Reporting Notice and Instructions for Completing Commercial Fire ACORD 67 MA 68 MN 2003/03 Minnesota Fair Plan Commercial Fire 68 ND 10/93a North Dakota Supplement to Property Ins 68 NJ 2003/07 New Jersey Insurance Under Assn - Commercial Fire App 68 NY 2002/01 New York Liability Supplement - Claims- Made Policy 68 OH 7/99 Ohio Offer Mine Subsidence Ins 68 RI 2003/04 Rhode Island Joint Reinsurance Association - for Commercial Fire Insurance Inspection and Placement 68 TX 2002/12 Texas Homeowners and Personal Prop (Spanish)

6 68 WV 2001/08 WV Umbrella Liability Supplement Uninsured/Underinsured Motorists Coverage (Single Limit) 69 FL 2002/07 Citizens Property Insurance Corporation, Wind Only Supplemental Residential Schedule 69 IL 2003/07 IL FAIR Plan App for Homeowners/Dwelling (Part 1 of 2) 69 LA 2002/06 Louisiana Auto Supplement 69 RI 2003/04 Rhode Island Joint Reinsurance Association - Inspection Notice, Credit Reporting Notice and Instructions for Completing Commercial Fire ACORD 68 RI 69 TX 2000/08 Texas Special Mobile Home Windstorm & Hail 70 NY 2000/09 NYPIUA Instructions for Completing for Commercial Insurance /09 Personal Policy Change Request (Except Auto) 71 SC 2003/03 Associated Auto Ins Plan of SC - Private Passenger Policy Change Request /09 Personal Auto Policy Change Request /12 Certification of Mobile Homes Tie-downs Supplement /08 Solid Fuel Questionnaire /05 Residence Based Business /01 Insurance Binder 76 9/93 Binder Log /04 Jewelry Insurance Appraisal - Single Item /04 Jewelry Insurance Appraisal /09 Homeowner /09 Personal Inland Marine /09 Watercraft /09 Personal Umbrella /09 Dwelling Fire /09 Mobile Home /09 Personal Lines Package /06 Personal Lines Package Watercraft/Inland Marine Supplement 90 AK 2001/02 Alaska Personal Auto 90 AL 2001/02 Alabama Personal Automobile 90 AR 2000/10 Arkansas Personal Automobile 90 AZ 2003/10 Arizona Personal Automobile 90 CA 2000/01 California Personal Auto 90 CO 2003/07 Colorado Personal Automobile 90 CT 2003/06 Connecticut Personal Automobile App 90 DC 2002/01 District of Columbia Personal Auto Appli 90 DE 2003/09 Delaware Personal Auto 90 FL 2003/10 Florida Personal Automobile 90 GA 2003/09 Georgia Personal Automobile 90 HI 2001/02 Hawaii Personal Automobile 90 IA 2002/10 Iowa Personal Auto 90 ID 2001/03 Idaho Personal Automobile 90 IL 2003/09 Illinois Personal Automobile 90 IN 2003/12 Indiana Personal Automobile 90 KS 2003/04 Kansas Personal Auto 90 KY 2002/07 Kentucky Personal Auto 90 LA 6/98 Louisiana Personal Automobile App 90 MA 2003/01 for Massachusetts Motor Vehicle Ins 90 MD 2003/05 Maryland Personal Automobile 90 ME 2003/11 Maine Personal Auto 90 MI 2003/04 Michigan Personal Automobile 90 MN 2003/07 Minnesota Personal Automobile App 90 MO 2002/09 Missouri Personal Automobile App 90 MS 2002/09 Mississippi Personal Auto 90 MT 2003/09 Montana Personal Auto 90 NC 2001/02 North Carolina Personal Auto 90 ND 2000/10 North Dakota Personal Auto

7 90 NE 2000/08 Nebraska Personal Auto 90 NH 2001/03 New Hampshire Personal Automobile App 90 NJ 2000/09 New Jersey Personal Automobile App 90 NM 2001/03 New Mexico Personal Automobile App 90 NV 2001/03 Nevada Personal Auto 90 NY 2003/11 New York Personal Automobile 90 OH 2003/09 Ohio Personal Automobile 90 OK 2001/03 Oklahoma Personal Automobile 90 OR 2003/05 Oregon Personal Automobile 90 PA 2000/09 Pennsylvania Personal Automobile App 90 PR 2001/03 Puerto Rico Personal Auto App. 90 RI 2003/05 Rhode Island Personal Auto 90 SC 2002/10 South Carolina Personal Auto 90 SD 9/98 South Dakota Personal Auto 90 TN 2000/11 Tennessee Personal Auto 90 TX 2001/03 Texas Personal Auto 90 UT 2001/01 Utah Personal Automobile 90 VA 2003/09 Virginia Personal Automobile 90 VI 2001/03 Virgin Islands Personal Automobile 90 VT 2003/06 Vermont Personal Automobile 90 WA 2000/08 Washington Personal Automobile App 90 WI 2001/03 Wisconsin Personal Automobile Appl 90 WV 2003/10 West Virginia Personal Auto 90 WY 2001/03 Wyoming Personal Automobile 91 3/93a Good Student Driver Training 92 2/95 Medical Statement /01 Young Driver Questionnaire 94 HI 2001/03 Hawaii Vehicle Inspection Report Supp 94 NJ 3/94 Insurance Inspection Report 95 MA 4/98 Massachusetts Renewal (Statement of Facts) 97 SC 2003/03 Assoc Auto Insurers Plan of SC - Private Passenger Auto App 97 WI 2003/10 Wisconsin Automobile Insurance Plan - Private Passenger Auto /01 Commercial Insurance Applicant Information Section /07 Commercial General Liability Section /08 Business Auto Section /05 Garage and Dealers Section 129 SC 2003/03 Assoc Ins Plan of SC - Vehicle Schedule /08 Vehicle Schedule 130 FL 2002/07 Florida Workers Comp /10 Workers Compensation /08 Umbrella Section 132 NJ 2000/04 NJ Workers Compensation Insurance Plan Instructions/Rules /05 Truckers/Motor Carriers Section 133 FL 2003/07 FL Workers Comp. Addendum to 130FL 133 MI 2003/02 MI for Workers Compensation Insurance 133 MT 8/98 Montana Worker s Comp. Supplement 133 NC 10/96 NC Workers Compensation 133 NJ 2003/05 NJ Workers Compensation Insurance 133 TN 2000/08 TN Assigned Risk Supplement 133 WI 2002/01 WI Workers Compensation Insurance Pool /10 Workers Compensation Insurance Plan - Assigned Risk 134 FL 2003/07 FL Workers Comp. Instructions 134 NC 10/96 NC Workers Compensation Insurance Plan 134 NJ 2001/07 NJ Workers Compensation Insurance Plan 134 WI 8/99 WI Supplementary Non-Election Form 135 NJ 2000/04 New Jersey Workers Compensation Insurance Plan Supplemental Employee Leasing 135 WI 8/99 WI Supplementary Election of Coverage 136 NJ 2000/04 NJ Workers Compensation

8 136 WI 7/96 WI Supp. Ltd. Other States Coverage Req. 137 AK 2001/06 Alaska Commercial Auto 137 AL 2001/06 Alabama Commercial Auto 137 AR 2000/10 Arkansas Commercial Auto 137 AZ 2003/10 Arizona Commercial Auto 137 CA 2001/06 California Commercial Auto 137 CO 2003/07 Colorado Commercial Auto 137 CT 2003/05 Connecticut Commercial Auto 137 DC 2000/09 District of Columbia Commercial Auto 137 DE 2001/06 Delaware Commercial Auto 137 FL 2003/10 Florida Commercial Auto 137 GA 2001/02 Georgia Commercial Auto 137 HI 2001/02 Hawaii Commercial Auto 137 IA 2002/10 Iowa Commercial Auto 137 ID 2002/09 Idaho Commercial Auto 137 IL 2003/03 Illinois Commercial Auto 137 IN 2000/08 Indiana Commercial Auto 137 KS 2002/07 Kansas Commercial Auto 137 KY 2002/09 Kentucky Commercial Auto 137 LA 2001/10 Louisiana Commercial Auto 137 MA 2000/09 Massachusetts Commercial Auto 137 MD 2001/06 Maryland Commercial Auto 137 ME 2000/09 Maine Commercial Auto 137 MI 2000/09 Michigan Commercial Auto 137 MN 2001/10 Minnesota Commercial Auto 137 MO 2001/10 Missouri Commercial Auto 137 MS 2003/04 Mississippi Commercial Auto 137 MT 2003/09 Montana Commercial Auto 137 NC 2002/10 North Carolina Commercial Auto 137 ND 2002/02 North Dakota Commercial Auto 137 NE 2001/10 Nebraska Commercial Auto 137 NH 2001/11 New Hampshire Commercial Auto 137 NJ 2002/08 New Jersey Commercial Auto 137 NM 2001/11 New Mexico Commercial Auto 137 NV 2001/11 Nevada Commercial Auto 137 NY 2003/11 New York Commercial Auto 137 OH 2002/11 Ohio Commercial Auto 137 OK 2001/11 Oklahoma Commercial Auto 137 OR 2002/02 Oregon Commercial Auto 137 PA 2002/11 Pennsylvania Commercial Auto 137 RI 2003/05 Rhode Island Commercial Auto 137 SC 2003/02 South Carolina Commercial Auto 137 SD 2002/02 South Dakota Commercial Auto 137 TN 2002/01 Tennessee Commercial Auto 137 TX 2002/02 Texas Commercial Auto 137 UT 2001/01 Utah Commercial Auto 137 VA 2002/12 Virginia Commercial Auto 137 VT 2003/06 Vermont Commercial Auto 137 WA 2002/08 Washington Commercial Auto 137 WI 2002/02 Wisconsin Commercial Auto 137 WV 2002/02 West Virginia Commercial Auto 137 WY 2002/02 Wyoming Commercial Auto 138 AK 4/97 Alaska Garage and Dealers 138 AL 2/97 Alabama Garage and Dealers 138 AR 2000/10 Arkansas Garage and Dealers 138 AZ 2003/10 Arizona Garage and Dealers 138 CA 3/96 California Garage and Dealers 138 CO 2003/07 Colorado Garage and Dealers 138 CT 2003/05 Connecticut Garage and Dealers 138 DC 2000/09 District of Columbia Garage and Dealers 138 DE 3/96 Delaware Garage and Dealers 138 FL 2003/10 Florida Garage and Dealers 138 GA 2001/02 Georgia Garage and Dealers 138 HI 2001/02 Hawaii Garage and Dealers 138 IA 2002/10 Iowa Garage and Dealers 138 ID 3/96 Idaho Garage and Dealers

9 138 IL 2003/03 Illinois Garage and Dealers 138 IN 2000/08 Indiana Garage and Dealers 138 KS 2002/07 Kansas Garage and Dealers 138 KY 2000/09 Kentucky Garage and Dealers 138 LA 6/98 Louisiana Garage and Dealers 138 MA 2000/09 Massachusetts Garage and Dealers 138 MD 2000/07 Maryland Garage and Dealers 138 ME 2000/09 Maine Garage and Dealers 138 MI 4/96 Michigan Garage and Dealers 138 MN 2001/10 Minnesota Garage and Dealers 138 MO 3/96 Missouri Garage and Dealers 138 MS 2003/04 Mississippi Garage and Dealers 138 MT 2003/09 Montana Garage and Dealers 138 NC 2000/09 North Carolina Garage and Dealers 138 ND 2000/07 North Dakota Garage and Dealers 138 NE 8/97 Nebraska Garage and Dealers 138 NH 3/96 New Hampshire Garage and Dealers 138 NJ 2002/08 New Jersey Garage and Dealers 138 NM 3/96 New Mexico Garage and Dealers 138 NV 3/96 Nevada Garage and Dealers 138 NY 2003/11 New York Garage and Dealers 138 OH 2002/11 Ohio Garage and Dealers 138 OK 3/96 Oklahoma Garage and Dealers 138 OR 2000/07 Oregon Garage and Dealers 138 PA 2002/07 Pennsylvania Garage and Dealers 138 RI 2003/05 Rhode Island Garage and Dealers 138 SC 2003/02 South Carolina Garage and Dealers 138 SD 2/97 South Dakota Garage and Dealers 138 TN 2002/01 Tennessee Garage and Dealers 138 TX 2000/08 Texas Garage and Dealers 138 UT 2001/01 Utah Garage and Dealers 138 VA 2002/12 Virginia Garage and Dealers 138 VT 2003/06 Vermont Garage and Dealers 138 WA 2002/08 Washington Garage and Dealers 138 WI 4/96 Wisconsin Garage and Dealers 138 WV 3/96 West Virginia Garage and Dealers 138 WY 3/96 Wyoming Garage and Dealers 139 MI 2002/03 Michigan Automobile Insurance Placement Facility Supplement to ACORD App. for Commercial, Public Automobiles and Corporately Owned Vehicles 139 MS 2/99 Mississippi Statement/Schedule of Values /07 Statement/Schedule of Values /09 Property Section 141 C 2002/12 Crime Section /07 Crime Section 143 9/91 Transportation Section /94 Glass And Sign Supplement /08 Accounts Receivable/Valuable Papers /09 Equipment Floater /02 Installation/Builder s Risk /02 Electronic Data Processing /02 Dealers Section /07 Miscellaneous Crime Coverage Section 154 1/98 Jeweler s Inventory Record-Keeping Card /11 Boiler & Machinery 155 BM 2003/08 Boiler & Machinery Section /07 Schedule of Insurance /03 Business Owners /11 Commercial Auto Driver Info. Schedule 170 OH 2002/09 Ohio FAIR Plan Underwriting Association - Instructions for Completion of Insurance s 171 AK 6/98 AK Petition For Executive Officer Waiver 171 CO 2002/12 CO Rejection of Cov g by Corp. Officers 171 CT 4/96 CT Workers Comp-Coverage for Officers

10 171 DE 7/96 Delaware Workers Comp. Election- form C 171 FL 2/97 FL Notice of Election of Coverage 171 GA 2001/03 GA Workers Comp - Corp. Officer Rejection 171 IL 2002/10 IL FAIR Plan App for Commercial Property Insurance 171 KS 2001/05 KS Elec. of Individual, Partner or Self- Employed Individual 171 MI 4/96 MI Notice of Election 171 NJ 2003/07 NJ Workers Compensation Insurance Plan NJ Workers Compensation and Employers Liability Manaul, Part 3, Section NM 7/96 NM Executive Employee Exemption 171 NY 10/96 NY Notice of Election of a Corporation 171 OH 2002/09 Ohio FAIR Plan Underwriting Association - for Insurance - Basic Property 171 PA 2002/02 PA App. for Executive Exemption 171 TN 2003/09 TN Notice of Election of Non-Acceptance 171 VA 2003/02 VA Rejection of Cov g-workers Comp Act 172 CT 4/96 CT Workers Comp. for Partnership Membrs 172 FL 5/99 FL Cert. of Exemption of Coverage 172 KS 2001/05 KS Cancel. of Elec. of Individual Partner or Self-Employed Ind. 172 MI 4/96 MI for Exclusion 172 NM 7/96 NM Election to Accept 172 NY 7/96 Cov g of Partners and Self-Employed 172 OH 2002/09 Ohio FAIR Plan Underwriting Association - for Insurance - Homeowners Supplement 172 PA 2002/02 PA Executive Officers Declaration 172 TN 2003/09 Notice of Corporate Officer s Revocation of Exemption 172 VA 2003/02 VA Notice Terminating Prior Rej. of Covg 173 CT 4/96 CT Workers Comp. for a Sole Proprietor 173 FL 10/99 Exemption Election for FL Worker Comp. 173 KS 2001/05 KS Cancel. of Elec. Not to Accept Coverage 173 MI 2000/09 MI Workers Comp Facility Specific Person Exclusion Form 173 NM 7/96 NM Revocation 173 NY 7/96 Executive Cov g-relig,charity,vet. orgs 173 OH 2002/09 Ohio FAIR Plan Underwriting Association Dwelling Fire Supplement 173 TN 2003/09 Election of Sole Proprietor or Partner to Come Within the Provisions of the Tennessee Workers Compensation Law 174 KS 2001/05 KS Election Not To Accept Coverage 174 NY 7/96 Revocation of Exec Cov g (form 173 NY) 174 OH 2002/09 Ohio FAIR Plan Underwriting Assn Commercial Supplement 174 TN 2003/09 Notice of Withdrawal of Sole Proprietor or Partner Election 175 FL 3/97 FL Workers Compensation Monthly Change Sheet 175 OH 2002/09 Ohio FAIR Plan Underwriting Assn Farm Supplement 175 SC 2003/03 Assoc Auto Ins Plan of SC - Comm Auto Policy Change Req /08 Commercial Policy Change Request 176 KS 2001/05 KS Election of Employer to Cover Employees 176 OH 2002/09 Ohio FAIR Plan Underwriting Association - Rehabilitation Supplement 177 CA 2001/03 CA Auto Body Repair Consumer Bill of Rights 177 KS 2001/05 KS Election of Coverage for Volunteer Workers 177 NY 2000/09 NYPIUA for Commercial Insurance 177 OH 2002/09 Ohio FAIR Plan Underwriting Assn Bowling Alley Supplement

11 177 SC 2003/03 Assoc Auto Ins Plan of SC - Comm Auto 177 WI 2003/10 WI Auto Insurance Plan - Business Auto 178 KS 2001/05 KS Cancel. of Election of Employer to Cover Employees 178 WI 2003/11 WI Auto Insurance Plan - Truckers 179 KS 2001/05 KS Cancel. of Election of Coverage for Volunteer Workers 179 SC 2003/03 Assoc Auto Ins Plan of SC - Garage 180 KS 2001/05 KS Election of Coverage for Persons Performing Public Service 180 1/97 Errors and Omissions Section 181 KS 2001/08 KS Cancel. Election of Coverage for Persons Performing Public Service 181 SC 2003/03 Assoc Auto Ins Plan of SC: Co Performance Complaint Form 182 KS 2001/05 KS Election of a Noncompensated Volunteer to be Covered 182 SC 2003/03 Assoc Auto Ins Plan - Producer Perform. Complaint Form 183 KS 2001/05 KS Cancellation Election of a Noncompensated Volunteer to be Covered 183 SC 2003/03 Assoc Auto Ins Plan of SC - Automobile Loss Notice 184 SC 2003/03 Assoc Auto Ins Plan of SC - Garage Supplemental Form 185 SC 2003/03 Assoc Auto Ins Plan of SC - Unin/Under Private Pass Risks /07 Restaurant/Tavern Supplement 186 SC 2003/03 Assoc Auto Ins Plan - Unin/Under Cvge for Comm Risks /09 Contractors Supplement 187 SC 2003/03 Assoc Auto Ins Plan of SC - Name and/or Ownership Change 187 3/98 Professional Liability Supplement 188 SC 2003/03 Assoc Auto Ins Plan of SC - Endorsement Voiding Auto Insurance While Named Person is Operating Car /02 Employment Related Practices Liability Section 190 1/96 Supplemental Property 192 7/98 Equine Insurance /02 Open Cargo Section /05 Truckers/Motor Carrier Supplement /96 Design Professional s Ind. Prop. Survey /08 Medical Professional Liability Insurance App /99 Supplement - Undertaking 200 3/93 Producer Account 201 3/93 Producer Account Discrepency Notice /05 Yacht Section 220 FL 2003/08 Citizens Property Insurance Corporation, Commercial and Commercial - Residential Wind Only 221 FL 2002/07 Citizens Property Insurance Corporation, Wind Only - Supplemental Schedule Commercial and Commercial - Residential 225 1/98 Policyholders Report 226 3/93 Statement of Premium Adjustment 301 3/97a Flood Insurance 302 3/97 Flood Insurance Gen l Change Endorsement /07 Flood Ins. Preferred Risk Policy App /97 Flood Ins. Cancellation/Nullification /05 Aviation Insurance - Applicant Information Section /04 Pilot Experience /02 NAIC Uniform App. for Individual Non- Resident License

12 /02 NAIC Uniform App. for Business Entity Non-Resident License/Registration /10 Agriculture /10 Agriculture Property Section /05 Agri-Business Property Section /05 Agri-Business Liability Section /05 Agriculture Premises Diagram /05 Small Farm/Ranch /02 Surety Report of Execution /09 Premium Payment Supplement /01 Railroad Protective Liability Supplement /01 Hotel/Motel Supplement /12 Jewelry Sales Receipt for Insurance Purposes 851 SC 2003/03 Assoc Auto Ins Plan of SC - Electronic App Submission Interface Retraction Request Form