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 #: E-Mail Address: Zip: 1 Property Loss Notice COUNTRYWIDE P&C FORMS 70 2012/03 2015/09 Personal Policy Change Request (Except Auto) 2 Automobile Loss Notice 71 2012/03 2015/09 Personal Auto Policy Change Request 3 General Liability Notice of Occur/Claim 72 2009/10 Mobile Home Supplement 4 11 12 13 23 24 25 5 Aircraft Loss Notice 2/95 2/95 2/95 2009/09 Workers Compensation - First Report of Injury or Illness 6 2009/05 Aviation Witness / Passenger Schedule 7 2009/05 Aviation Injured Schedule Auto Accident Information Form Exchange of Information Form Witness Card 20 2009/12 Certificate of Aviation Liability Insurance 21 2009/12 Certificate of Aircraft Insurance 22 2012/04 Intermodal Interchange Certificate of Insurance 2010/05 2014/01 Vehicle or Equipment Certificate of Insurance Certificate of Property Insurance Certificate of Liability Insurance 73 2009/07 Solid Fuel Questionnaire - Supplement to Residential Section 74 82 83 88 2009/09 76 9/93 Binder Log Residence Based Business Supplement to Residential Section 75 Insurance Binder 80 Homeowner Application 81 Personal Inland Marine Application Watercraft Application Personal Umbrella Application 84 Dwelling Fire Application 85 Mobile Home Application 89 Residential Section Personal Insurance Application - Applicant Information Section 26 2002/01 Policy Certification Log 91 2009/10 Good Student Driver Training 27 2009/12 Evidence of Property Insurance 92 2012/03 Medical Statement 28 2014/01 Evidence of Commercial Property Insurance 93 2012/03 Young Driver Questionnaire 29 Evidence of Flood Insurance 30 2014/01 Certificate of Garage Insurance 31 2014/01 Certificate of Marine / Energy Insurance 35 36 37 38 2011/09 2007/01 2008/01 Cancellation Request / Policy Release Agent/Broker of Record Change Statement of No Loss Notice of Insurance Information Practices (Privacy) 42 2014/08 Residential Property Replacement Cost 99 2009/02 Accidents / Convictions Schedule 101 2008/01 Additional Remarks Schedule 103 125 126 2012/03 Personal Auto Application Schedule - Additional Resident and Driver Information Section 105 2012/06 Apartment Building Supplement 106 2010/04 Vacant Building Supplement 2014/04 Commercial Insurance Application Applicant Information Section Commercial General Liability Section 45 2009/04 Additional Interest Schedule 127 Business Auto Section 50 2007/02 Automobile Insurance ID Card 128 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 Workers Compensation Application 57 1/97 Financial Responsibility Form - Cancellation 131 Umbrella Section 58 2007/11 Notice of Cancellation or Termination of Policy 60 60 US 62 US 2010/04 63 Fraud Statements 64 US 66 2011/05 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 68 2013/08 Electronic Delivery Supplement 132 133 139 140 141 2015/06 2014/09 Truckers / Motor Carriers Section Workers Compensation Insurance Plan - Assigned Risk Section Statement / Schedule of Values Property Section Crime Section 2000 143 Transportation Section 144 Glass And Sign Section 145 Accounts Receivable / Valuable Papers 147 Installation / Builders Risk Section Page 1 of 12
ACORD Forms Index COUNTRYWIDE P&C FORMS - continued 148 Electronic Data Processing Section 340 2009/06 Aircraft Change Request 149 Dealers Section 341 2011/11 Pilot Experience Change Request 152 2015/06 Commercial Inland Marine Section 342 2009/06 Hangar Change Request 155 BM Boiler & Machinery Section 2002 350 Watermark Paper - 20 # ID Card Stock (4-part perforation) 159 2014/09 Schedule of Insurance 360 Watermark Paper - 32 # ID Card Stock (4-part perforation) 160 2015/06 Business Owners Section 370 Watermark Paper - 32 # ID Card Stock (non-perforated) 163 2012/06 Commercial Auto Driver Information Schedule 401 Agriculture Application 175 2012/04 Commercial Policy Change Request 402 Agriculture Property Section 180 Errors and Omissions Section - Electronic Data Processors, Electronic Products Manufacturers, Computer Services etc. 403 Agriculture Property Section Scheduled / Unscheduled Personal Property 185 2011/09 Restaurant / Tavern Supplement 404 Agriculture Liability Section 186 2011/10 187 3/98 188 190 193 Contractors Supplement Professional Liability Supplement Employment Related Practices Liability Section Supplemental Property Application Open Cargo Section 194 2009/03 Truckers / Motor Carrier Supplement 195 10/96 Design Professional's Individual Property Survey 196 Medical Professional Liability Insurance Application 199 1/99 Application Supplement - Undertaking 200 3/93 Producer Account 201 3/93 Producer Account Discrepancy Notice 210 Yacht Section 225 1/98 Policyholder's Report 226 3/93 Statement of Premium Adjustment 275 2009/05 Aviation Insurance Binder 276 2009/05 Aircraft Insurance Binder 281 Personal Inland Marine Section 405 2007/09 406 2007/09 407 408 2007/09 410 501 2004/07 610 801 802 803 807 810 811 502 2015/04 611 2009/04 Premium Payment Supplement 2002/01 Railroad Protective Liability Supplement 2011/09 808 2010/08 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 Contract Bond Request Form 2015/07 Claims History / Loss Run Request 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 282 Watercraft Section 812 2006/02 Agency Questionnaire 283 301 302 303 304 305 2015/04 306 2011/04 307 308 325 326 327 328 329 330 331 2015/04 2015/04 2015/04 2012/02 2015/04 2015/04 Personal Umbrella Application Section National Flood Insurance Program Flood Insurance Application NFIP - Flood Insurance General Change Endorsement NFIP - Flood Insurance Preferred Risk Policy Application NFIP - Flood Insurance Cancellation / Nullification NFIP - Credit Card Payment Form NFIP - Rating Information and Elevated Building Determination Form NFIP - Floodproofing Certificate for Non-Residential Structures NFIP - Residential Basement Floodproofing Certificate Aviation Insurance Application - Applicant Information Section 2006/04 Airport Property Supplement 2011/11 Airport and FBO Liability Section Private Hangar Liability Section Aviation Products Liability Aircraft Section Pilot Experience 813 815 816 821 822 825 2005/03 Request for Proof of Property Insurance 2009/02 823 2011/10 827 828 International Liability Exposure Supplement 2005/06 International Property Exposure Supplement 2009/07 829 2009/05 830 2008/11 831 832 833 834 838 Producer Information Form (PIF) Driver Work / School Address Information Supplement Additional Premises Information Schedule Professional / Specialty Insurance Application - For Use in Management, Executive & Professional Lines Applicant Section Employment Practices Liability Insurance Section Fiduciary Liability Coverage Section Forms and Endorsements Schedule Property Insurance Card Professional / Specialty Insurance Notice of Incident / Claim Miscellaneous E&O Section Lawyers Professional Liability Section Cyber and Privacy Coverage Section Accountants Professional Liability Section 332 2006/04 Hangar Schedule 333 335 2009/06 336 2009/05 Aircraft Schedule 2009/06 Aviation Policy Change Request Applicant Information Section Airport Property Change Request 337 2009/06 Airport and FBO Liability Change Request 338 2009/06 Private Hangar Liability Change Request 339 2009/06 Aviation Products Liability Change Request Page 2 of 12
ACORD Forms Index STATE P&C FORMS Alabama 50 AL 2007/10 Alabama Insurance Identification Card 90 CA California (continued) California Personal Auto Application 62 AL 5/98 Alabama Insurance Application Supplement 137 CA California Commercial Auto 90 AL Alabama Personal Auto Application 138 CA California Garage and Dealers 137 AL Alabama Commercial Auto 177 CA 2015/09 California Auto Body Repair Consumer Bill of Rights 138 AL 290 AL 61 AK 62 AK 90 AK 137 AK 138 AK Alabama Garage and Dealers Alabama Personal Automobile Application Section Alaska 7/97 Alaska Auto Supplement - UM/UIM Coverage Selection 2/98 Alaska Auto Supplement - Exclusion of Named Drivers Alaska Personal Auto Application Alaska Commercial Auto Alaska Garage and Dealers 290 CA California Personal Auto Application Section 854 CA 855 CA 856 CA 857 CA 2011/02 California FAIR Plan Property Insurance - Application for Dwelling Insurance California FAIR Plan Property Insurance - Application for Commercial Insurance California FAIR Plan Property Insurance - Application for Businessowners (BOP) Insurance California Earthquake Authority - Application for Earthquake Insurance 860 CA 2004/12 California Auto Supplement - Driver Self Certification 171 AK 290 AK 50 AR 67 AR 2000/02 90 AR 137 AR 138 AR Arizona 38 AZ 2003/10 Arizona Notice of Information Practices (Privacy) 50 AZ 2012/08 Arizona Insurance Identification Card 61 AZ 2001/02 Arizona Auto Supplement UM/UIM Coverage Selection 90 AZ 137 AZ 138 AZ 290 AZ 6/98 Alaska Petition For Executive Officer Waiver 2007/10 Alaska Personal Auto Application Section Arkansas Arkansas Proof of Insurance Card 61 AR 2010/04 Arkansas Auto Supplement UM/UIM Coverage 62 AR Arkansas Personal Umbrella Supplement Arkansas Property Supplement - Declination of Residential Earthquake Coverage Arkansas Personal Auto Application Arkansas Commercial Auto Arkansas Garage and Dealers 290 AR Arkansas Personal Auto Application Section 61 CA 64 CA 65 CA 66 CA 188 AR 807 AR 827 AR 828 AR 832 AR 833 AR 834 AR 838 AR 2011/04 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 2008/03 2004/02 2004/07 Arkansas Employment Related Practices Liability Section Arkansas Directors & Officers Liability Section Arkansas Employment Practices Liability Insurance Section Arkansas Fiduciary Liability Coverage Section Arkansas Miscellaneous E&O Section Arkansas Lawyers Professional Liability Section Arkansas Cyber and Privacy Coverage Section Arkansas Accountants Professional Liability Section 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 861 CA 2011/07 California Residential Property Insurance Bill of Rights 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 2010/01 2015/02 2006/08 2006/08 2006/08 Connecticut 50 CT 2009/01 Connecticut Insurance Identification Card 62 CT 2006/01 2011/07 Colorado 50 CO 2007/03 Colorado Insurance Identification Card 64 CO 65 CO 66 CO 67 CO 68 CO 69 CO 2012/01 2009/01 2013/02 2013/02 2013/02 2013/02 2014/01 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 Property Supplement - Homeowner's Insurance Replacement-Cost Policy Applicants Colorado Personal Automobile Application Colorado Commercial Auto Colorado Garage and Dealers Colorado Rejection of Coverage by Corporate Officers 290 CO 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 Connecticut Personal Automobile Application Section 67 CA 68 CA 2011/07 2001/03 California Residential Property Insurance Disclosure California Scheduled Personal Property Loss Computation Disclosure 69 CA California Insurance Supplement Page 3 of 12
ACORD Forms Index STATE P&C FORMS 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 Delaware Commercial Auto 138 DE 2008/04 2007/03 2006/10 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 Insurance Placement Facility of Delaware Basic Property Insurance Application 67 DE 2012/01 Delaware Insurance Supplement 62 DC 64 DC 66 DC 67 DC 68 DC 90 DC Delaware Garage and Dealers Delaware Executive Officer(s) Exclusion Delaware Personal Auto Application Section 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 221 FL 2002/07 860 FL 2011/11 862 FL 863 FL Florida (continued) Citizens Property Ins Corp, Wind Only - Supplemental Application Schedule Commercial and Commercial - Residential 283 FL Florida Personal Umbrella Application Section 90 GA 137 GA 138 GA 171 GA 2013/05 Florida Commercial Auto Addendum Florida Personal Auto Supplement Florida Personal Auto Supplement Georgia 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 Georgia Personal Auto Application Georgia Commercial Auto Georgia Garage and Dealers Georgia State Board of Workers' Compensation - Notice of Election or Rejection of Workers' Compensation Coverage 290 GA Georgia Personal Automobile Application Section 137 DC District of Columbia Commercial Auto 138 DC District of Columbia Garage and Dealers 290 DC District of Columbia Personal Auto Application Section Florida 50 FL 2009/07 Florida Personal Auto ID Card 51 FL 61 FL 62 FL 64 FL 65 FL 2007/08 66 FL 2009/07 2011/10 2011/10 67 FL 7/94 70 FL 2012/02 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 Insurance Supplement Credit Report Disclosure Information Florida Homeowners Supplement Florida Property Supplement Uniform Mitigation Verification Inspection Form 83 FL Florida Personal Umbrella Application 90 FL 125 FL 130 FL 133 FL 2014/01 2015/02 Florida Personal Auto Application Florida Commercial Insurance Application Applicant Information Section 2015/02 Florida Workers Compensation Application 2013/03 Florida Workers Comp. Addendum to ACORD 130 FL 137 FL Florida Commercial Auto 138 FL 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 220 FL 3/97 Florida Workers Compensation Monthly Change Sheet 2012/12 Citizens Property Insurance Corporation Commercial - Residential Wind Only Page 4 of 12
61 IL 62 IL 90 IL ACORD Forms Index STATE P&C FORMS - continued 50 HI 60 HI 90 HI 94 HI 137 HI 138 HI 290 HI 137 ID 138 ID 50 IL 2007/03 137 IL 138 IL 171 IL 90 IN 2007/08 67 IL 2012/01 2008/01 Hawaii Auto ID Card 2005/06 Hawaii 2010/07 Hawaii Auto Supplement - UM/UIM/PIP Hawaii Personal Auto Application 2001/03 Hawaii Vehicle Inspection Report Supplement 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 Idaho Personal Auto Application Idaho Auto Supplement - Idaho Uninsured Motorist and Underinsured Motorist Disclosure Statement Idaho Commercial Auto Idaho Garage and Dealers 290 ID Idaho Personal Automobile Application Section 67 2015/07 Illinois Illinois Insurance Identification Card Illinois Auto Supplement - UM/UIM Illinois Property Supplement - Notice of Availability of Earthquake Insurance 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 Illinois Personal Auto Application Section Indiana 50 IN 2007/11 Indiana Insurance Identification Card 67 2015/07 Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement Indiana Personal Auto Application 38 KS 90 KS 137 KS 138 KS 171 KS 172 KS 173 KS 174 KS 176 KS 177 KS 178 KS 179 KS 180 KS 181 KS 182 KS 183 KS 290 KS 2001/05 2001/05 Kansas Kansas Personal Insurance Supplement - Notice of Insurance Information Practices Kansas Personal Auto Application Kansas Commercial Auto Kansas Garage and Dealers Kansas Elec. of Individual, Partner or Self-Employed Individual Kansas Cancel. of Elec. of Individual, Partner or Self-Employed Individual Kansas Cancellation of Election Not to Accept Coverage Kansas Election Not to Accept Coverage Kansas Election of Employer to Cover Employees Kansas Election of Coverage for Volunteer Workers Kansas Cancellation of Election of Employer to Cover Employees Kansas Cancel. of Election of Coverage for Volunteer Workers Kansas Election of Coverage for Persons Performing Public Service Kansas Cancellation of Election of Coverage for Persons Performing Public Service Kansas Election of a Noncompensated Volunteer to be Covered Kansas Cancellation of Election of a Noncompensated Volunteer to be Covered Kansas Personal Auto Application Section Kentucky 50 KY 2006/01 Commonwealth of Kentucky Proof of Insurance 60 KY 64 KY 2011/01 Kentucky FAIR Plan Homeowners Application 65 KY 2011/01 Kentucky FAIR Plan Dwelling Fire Application 66 KY 2011/01 Kentucky FAIR Plan Farm Fire Application 67 2015/07 68 KY 2011/01 Kentucky FAIR Plan Commercial Fire Application 90 KY 2015/09 2015/09 Kentucky Auto Supplement - Rejection of Uninsured / Underinsured Motorist Coverage Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement Kentucky Personal Auto Application 137 IN Indiana Commercial Auto 137 KY 2015/09 Kentucky Commercial Auto 138 IN Indiana Garage and Dealers 138 KY 2015/09 Kentucky Garage and Dealers 290 IN Indiana Personal Auto Application Section Iowa 50 IA 2007/08 Iowa Financial Responsibility Card 290 KY 2015/09 Kentucky Personal Auto Application Section 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 Iowa Personal Auto Application 137 IA Iowa Commercial Auto 138 IA Iowa Garage and Dealers 290 IA Iowa Personal Automobile Application Section Page 5 of 12
137 LA 39 MD 62 MD 1/98 64 MD 65 MD 66 MD 90 MD 2003/05 67 MD 2011/01 68 MD 2007/01 69 MD Louisiana 50 LA 2008/03 Louisiana Auto ID Card 60 LA 4/98 Louisiana Dwelling Supplement - Loss Settlement DWG1 61 LA 62 LA 64 LA 65 LA 66 LA 68 LA 2001/05 4/98 2001/05 2001/02 4/98 4/98 Louisiana Plan Services Application for Insurance 90 LA Louisiana Personal Auto Application Louisiana Commercial Auto 138 LA Louisiana Garage and Dealers Maine 50 ME 2007/08 Maine Motor Vehicle Insurance Identification Card 90 ME Maine Personal Auto Application 137 ME Maine Commercial Auto 138 ME Maine Garage and Dealers 290 ME Maine Personal Auto Application Section Maryland Maryland Commercial Auto Supplement Maryland Personal Auto Application ACORD Forms Index Louisiana Homeowners Supplement - Loss Settlement (HO4) Louisiana Commercial Property Supplement Louisiana Homeowners Supplement Loss Settlement (HO2 & 3) Louisiana Homeowners Supplement - Loss Settlement (HO6) Louisiana Dwelling Supplement - Loss Settlement DWG2 & 3 67 LA 5/98 Louisiana Certification of Mobile Home Tie Downs 290 LA Louisiana Personal Auto Application Section 861 LA 862 LA 2005/07 2009/06 Louisiana Auto Supplement - Active Military Personnel Affidavit Louisiana Property Supplement - Hurricane Loss Mitigation Survey Maryland Application Supp Notice of Intent to Use Credit History Maryland Property Insurance Availability Program Essential Property Insurance Inspection and Placement Maryland Property Insurance Availability Program - Essential Homeowners Insurance Inspection and Placement (p. 1 of 2) Maryland Property Insurance Availability Program - Essential Homeowners Insurance Inspection and Placement (p. 2 of 2) Maryland Personal Auto Supplement - Mandatory Offer of Increased Liability Coverage for Claims of Family Members, Mandatory PIP Waiver, and Mandatory UM Coverage Waiver Maryland Personal Property Supplement - Statement Regarding Flood Insurance Maryland Insurance Supplement - Notice of Underwriting Period STATE P&C FORMS - continued 60 MA 61 MA 64 MA 65 MA 66 MA 67 MA 68 MA 90 MA 95 MA 137 MA 138 MA 2003/04 2003/04 2003/04 69 MA 2010/07 50 MI 60 MI 62 MI 64 MI 90 MI 133 MI 137 MI 138 MI 139 MI 171 MI 172 MI 173 MI 290 MI 860 MI 2012/07 2/97 2012/08 2009/12 2012/02 2012/02 2004/07 2005/01 4/96 2000/09 Massachusetts Massachusetts Property Insurance Underwriting Association Application for Homeowners Insurance Massachusetts Property Insurance Underwriting Association Instructions to Complete Homeowners Application ACORD 60 MA Massachusetts Residential Property Liability Supplement Lead Poisoning Liability Disclosure Notice Massachusetts Property Insurance Underwriting Association Application for Dwelling Fire and Liability Insurance Inspection and Placement Massachusetts Property Ins Underwriting Assn - Instructions for Completing Dwelling Fire and Liability Insurance Application ACORD 65 MA Massachusetts Property Ins Underwriting Assn - Application for Commercial Fire Insurance Inspection and Placement Massachusetts Property Insurance Underwriting Association Inspection Notice, Credit Reporting Notice and Instructions for Completing Commercial Fire Application ACORD 67 MA Massachusetts Residential Property Liquid Fuel Spill Supplement Application for Massachusetts Motor Vehicle Insurance Massachusetts Renewal Application (Statement of Facts) Massachusetts Commercial Auto Massachusetts Garage and Dealers Michigan 2010/08 State of Michigan Certificate of No-Fault Insurance 2010/03 2014/03 2000/10 2012/08 Michigan Automobile Insurance Placement Facility Michigan Auto Supplement - Declaration of Intent to Reside Michigan Collision Insurance Options Notice Michigan Basic Property Insurance Assn Insurance Application Michigan Personal Auto Application Michigan Application for Workers' Compensation Insurance Michigan Commercial Auto Michigan Garage and Dealers Michigan Automobile Insurance Placement Facility Supplement to ACORD App. - Application for Commercial, Public Automobiles and Corporately Owned Vehicles Michigan Notice of Election Michigan Application for Exclusion of Partner(s), Spouse, Child or Parent Michigan WC Placement Facility Specific Person Exclusion Michigan Personal Automobile Application Section 2010/03 Michigan Auto Supplement - Declaration of Intent to Reside 137 MD Maryland Commercial Auto 138 MD Maryland Garage and Dealers 290 MD Maryland Personal Automobile Application Section 851 MD 2008/11 852 MD 2012/10 Maryland Personal Property Supplement - Loss from Water and Sewer Backup Maryland Personal Property Supplement - Homeowner's Insurance, Limitation of Claims Made Notice 853 MD 2014/01 Maryland Personal Property Supplement Page 6 of 12
ACORD Forms Index STATE P&C FORMS - continued 38 MN Minnesota Minnesota Authorization Nebraska 50 NE 2007/01 Nebraska Auto Liability Insurance Identification Card 62 MN 2000/01 Minnesota Auto Supplement 90 NE Nebraska Personal Auto Application 65 MN 2012/04 Minnesota Insurance Guarantee Association Notice 137 NE Nebraska Commercial Auto 90 MN Minnesota Personal Auto Application 138 NE Nebraska Garage and Dealers 137 MN Minnesota Commercial Auto 290 NE Nebraska Personal Auto Application Section 138 MN Minnesota Garage and Dealers Nevada 188 MN Minnesota Employment Related Practices Liability Section 51 NV Nevada Temporary Insurance Identification Card 290 MN 50 MS 61 MS 90 MS 137 MS 138 MS 139 MS 290 MS 50 MO 67 MO 90 MO 137 MO 138 MO 807 MN 827 MN 828 MN 832 MN 833 MN 834 MN 838 MN 853 MN 2010/08 2008/01 2013/07 2/99 2007/05 62 MO 2007/08 2009/06 Minnesota Personal Auto Application Section Minnesota Directors & Officers Liability Section Minnesota Employment Practices Liability Insurance Section Minnesota Fiduciary Liability Coverage Section Minnesota Miscellaneous E&O Section Minnesota Lawyers Professional Liability Section Minnesota Cyber and Privacy Coverage Section Minnesota Accountants Professional Liability Section Minnesota Homeowners Personal Property Supplement Mississippi Mississippi Auto Insurance ID Card Mississippi Auto Supplement - Non-Stacking UM Insurance Mississippi Personal Auto Application Mississippi Commercial Auto Mississippi Garage and Dealers Mississippi Statement/Schedule of Values Mississippi Personal Auto Application Section Missouri Missouri Auto Insurance ID Card Missouri Property Supplement - Notice of Availability of Earthquake Insurance Missouri FAIR Plan Insurance Application Missouri Personal Auto Application Missouri Commercial Auto Missouri Garage and Dealers 290 MO Missouri Personal Auto Application Section Montana 60 MT 2003/09 Montana Application Supplement - Refusal to Renew 52 NV 53 NV 54 NV 61 NV 62 NV 90 NV 137 NV 138 NV 290 NV 90 NH 137 NH 138 NH 290 NH 60 NJ 62 NJ 64 NJ 2011/05 2011/05 2002/12 2001/05 2001/10 2006/10 Nevada Permanent Insurance Identification Card Nevada Temporary Insurance Identification Card, Evidence of Operator's Policy of Liability Insurance Nevada Permanent Insurance Identification Card, Evidence of Operator's Policy of Liability Insurance Nevada Auto Supplement, Mandatory Offer of Medical Payments Coverage and Uninsured Motorists Coverage Nevada Umbrella Supplement Nevada Personal Auto Application Nevada Commercial Auto Nevada Garage and Dealers Nevada Personal Auto Application Section New Hampshire New Hampshire Personal Auto Application New Hampshire Commercial Auto New Hampshire Garage and Dealers New Hampshire Personal Auto Application Section New Jersey 50 NJ 2005/05 Temporary State of New Jersey Insurance Identification Card 51 NJ 2007/06 Permanent State of New Jersey Insurance Identification Card New Jersey Homeowners Insurance Supplement Flood Exclusion 61 NJ 2011/07 New Jersey Auto Insurance Buyer's Guide New Jersey Auto Supplement - Basic Policy Coverage 2010/03 New Jersey Auto Supplement - Standard Policy Coverage 65 NJ 2003/02 New Jersey Property Insurance Supplement - Earthquake 66 NJ 2011/07 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 MT Montana Personal Auto Application 90 NJ New Jersey Personal Auto Application 137 MT Montana Commercial Auto 138 MT Montana Garage and Dealers 188 MT Montana Employment Related Practices Liability Section 290 MT Montana Personal Auto Application Section 807 MT Montana Directors & Officers Liability Section 827 MT Montana Employment Practices Liability Insurance Section 828 MT Montana Fiduciary Liability Coverage Section 832 MT Montana Miscellaneous E&O Section 833 MT Montana Lawyers Professional Liability Section 834 MT Montana Cyber and Privacy Coverage Section 838 MT Montana Accountants Professional Liability Section 94 NJ 2006/04 Insurance Inspection Report 132 NJ 2013/07 133 NJ 134 NJ 135 NJ 136 NJ 137 NJ 2007/01 2009/09 New Jersey Workers Compensation Insurance Plan Notes and Instructions (Coverage Request Form) New Jersey Workers Compensation Insurance Plan Coverage Request Form New Jersey Workers Compensation Insurance Plan Notice of Election - Proprietors and Partners New Jersey Workers Compensation Insurance Plan Employee Leasing Supplemental Request Form New Jersey Workers Compensation Insurance Plan Truckers Supplemental Request Form New Jersey Commercial Auto 138 NJ New Jersey Garage and Dealers 171 NJ 290 NJ 2013/07 2009/09 2003/07 New Jersey Workers Compensation Insurance Plan - NJ Workers Compensation and Employers Liability Manual Part 3, Section 14 New Jersey Personal Auto Application Section Page 7 of 12
ACORD Forms Index STATE P&C FORMS - continued 60 NM 61 NM 90 NM New Mexico 2003/01 New Mexico Confidential Abuse Disclosure 2010/12 New Mexico Auto Supplement - UM Coverage Selection / Rejection and Rejection of Stacked UM Coverage New Mexico Personal Auto Application 38 ND 2005/08 North Dakota North Dakota Personal Insurance Supplement - Notice of Information Practices 50 ND 2007/08 North Dakota Insurance Identification Card 62 ND 2015/04 North Dakota Insurance Supplement 137 NM New Mexico Commercial Auto 68 ND 2004/07 North Dakota Supplement to Property Insurance - Fire District 138 NM New Mexico Garage and Dealers 90 ND North Dakota Personal Auto Application 171 NM 2004/10 New Mexico Executive Employee Affirmative Election Form 137 ND North Dakota Commercial Auto 172 NM 2004/10 New Mexico Election to Accept 138 ND North Dakota Garage and Dealers 173 NM 2004/10 174 NM 2004/10 290 NM 38 NY 2005/04 39 NY 2011/03 60 NY 2008/03 New Mexico Revocation New Mexico Limited Liability Company Member Affirmative Election Form New Mexico Personal Auto Application Section New York New York Personal Insurance Supplement - Notice of Information Practices New York Insurance Supplement New York Homeowners Supplement 290 ND North Dakota Personal Auto Application Section 62 OH 2011/05 67 OH 2009/07 68 OH 2009/07 Ohio 90 OH Ohio Personal Auto Application 137 OH Ohio Commercial Auto Ohio Auto Supplement - Important Optional Disclosure Notice Uninsured Motorist Property Damage Coverage Ohio Mine Subsidence Homeowners and Dwelling Supplement Ohio Offer of Mine Subsidence - Homeowners and Dwelling 61 NY 3/94 62 NY 2009/04 64 NY 2008/06 65 NY New York Auto Supplement (Optional Basic Econ Loss) New York Application For Dwelling Insurance - NYPIUA New York Auto Supplement - Supp UM/UIM Insurance Coverage 2003/01 New York Auto Supplement - Spousal Liability Coverage 138 OH Ohio Garage and Dealers 170 OH 2002/09 Ohio FAIR Plan - Instructions for Completion of Insurance Apps 171 OH 2004/03 Ohio FAIR Plan - Basic Property Application 172 OH 2002/09 Ohio FAIR Plan - Homeowners Supplement 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 69 NY 2008/08 70 NY 2006/04 90 NY 137 NY 138 NY 171 NY 10/96 172 NY 7/96 173 NY 174 NY 7/96 177 NY 290 NY 64 NC 65 NC 7/96 2006/04 855 NY 2014/05 2008/04 2010/02 66 NC 8/97 67 NC 2012/03 New York Liability Supplement - "Claims-Made Policy" New York Personal Property Supplement - Important Flood Insurance Notice NYPIUA Instructions for Completing ACORD 177 NY New York Personal Auto Application New York Commercial Auto New York Garage and Dealers New York Notice of Election of a Corporation New York Election of Partners or Self-Employed Persons for Workers Compensation Coverage New York Election of Executive Officers of an Organization for Workers Compensation Coverage New York Revocation of Executive Officers of an Organization for Workers Compensation Coverage NYPIUA Application for Commercial Insurance New York Personal Auto Application Section New York Construction Certificate of Liability Insurance Addendum North Carolina North Carolina Property Supplement - Prop Ins Notice Disclosure North Carolina Auto Supplement - Notice of Right to Purchase Higher Limits of Uninsured Motorist (UM) and Underinsured Motorist (UIM) Coverage North Carolina Insurance Supplement - Consent to Obtain Credit or Consumer Investigative Report North Carolina Insurance Supplement - Policy Service Fee Schedule 90 NC North Carolina Personal Auto Application 175 OH 2002/09 Ohio FAIR Plan - Farm Supplement 176 OH 2002/09 Ohio FAIR Plan - Rehabilitation Supplement 177 OH 2002/09 Ohio FAIR Plan - Bowling Alley Supplement 290 OH Ohio Personal Automobile Application Section Oklahoma 50 OK 2009/08 Oklahoma Owners Security Verification Form 51 OK 2009/08 Oklahoma Operators Security Verification Form 60 OK 2009/11 Oklahoma Auto Supplement - UM Coverage Law 62 OK 2006/05 90 OK Oklahoma Personal Auto Application 137 OK 138 OK Oklahoma Property Supplement Notice to Property Owners in Rural Fire Protection Districts 64 OK 2007/10 Oklahoma Liability Supplement Oklahoma Commercial Auto Oklahoma Garage and Dealers 290 OK Oklahoma Personal Auto Application Section 38 OR 61 OR 2004/10 Oregon Oregon Notice of Information Practices (Privacy) Oregon Auto Supplement - UM Coverage Selection 62 OR 2006/01 Oregon Personal Lines Supplement 90 OR Oregon Personal Auto Application 137 OR Oregon Commercial Auto 138 OR Oregon Garage and Dealers 290 OR Oregon Personal Auto Application Section 135 NC 136 NC 2012/10 2012/10 North Carolina Workers Comp Insurance Plan - Application NCWCIP, Instructions for Completing ACORD 135 NC App 137 NC North Carolina Commercial Auto 138 NC North Carolina Garage and Dealers 290 NC North Carolina Personal Automobile Application Section Page 8 of 12
ACORD Forms Index STATE P&C FORMS - continued 50 PA 60 PA 62 PA 64 PA 66 PA 90 PA 2007/09 2012/10 61 PA 2014/02 65 PA / DE / WV 2012/10 Pennsylvania Pennsylvania Financial Responsibility Card Pennsylvania UM Coverage Select/Reject Pennsylvania Auto Supplement - Important Notice Pennsylvania UIM Coverage Select/Reject Insurance Placement Facility of Pennsylvania Basic Property Insurance Application FAIR Plan Supplementary Questionnaire Insurance Placement Facility of Pennsylvania Dwelling Property 2 - Broad Form Application Supplement Pennsylvania Personal Auto Application 50 SC 61 SC 64 SC 90 SC 137 SC 138 SC 290 SC 2008/03 South Carolina 2007/01 South Carolina Insurance Identification Card 2007/08 South Carolina Auto Supplement - Offer of Opt UM/UIM Coverage South Carolina Personal Property Supplement - Cancellation Rules Disclosure South Carolina Personal Auto Application South Carolina Commercial Auto South Carolina Garage and Dealers South Carolina Personal Automobile Application Section South Dakota 50 SD 2007/02 South Dakota Insurance Identification Card 137 PA Pennsylvania Commercial Auto 61 SD 2013/02 South Dakota Personal Umbrella Supplement 138 PA Pennsylvania Garage and Dealers 90 SD South Dakota Personal Auto Application 171 PA 2002/02 Pennsylvania Application for Executive Officer Exception 137 SD South Dakota Commercial Auto 172 PA 2002/02 Pennsylvania Executive Officers Declaration 138 SD South Dakota Garage and Dealers 290 PA Pennsylvania Personal Auto Application Section Puerto Rico 90 PR Puerto Rico Personal Auto Application 290 SD 50 TN 2007/02 South Dakota Personal Auto Application Section Tennessee Tennessee Insurance Identification Card 290 PR 61 RI 64 RI 65 RI 2003/04 66 RI 67 RI 2007/03 68 RI 2003/04 69 RI 90 RI 137 RI 138 RI 290 RI 2012/12 2003/04 Rhode Island 50 RI 2008/01 Rhode Island Insurance Identification Card Rhode Island Auto Supplement, Uninsured / Underinsured Motorist Bodily Injury Coverage 62 RI 2006/01 Rhode Island Prop Suppl - Notice of Flood Coverage Exclusion 2012/07 2012/07 Puerto Rico Personal Auto Application Section Rhode Island Joint Reinsurance Association, Application for Homeowners Insurance Inspection and Placement Rhode Island Joint Reinsurance Association, Instructions for Completing Homeowners Application ACORD 64 RI Rhode Island Joint Underwriting Insurance Application for Dwelling Fire and Personal Liability Insurance Inspection and Placement Rhode Island Joint Underwriting Insurance Inspection Notice, Credit Reporting Notice and Instructions for Completing Dwelling Fire and Personal Liability Application ACORD 66 RI 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 Rhode Island Personal Auto Application Rhode Island Commercial Auto Rhode Island Garage and Dealers Rhode Island Personal Automobile Application Section 90 TN 137 TN 138 TN 290 TN 50 TX 60 TX 62 TX 64 TX 2003/04 67 TX 68 TX 69 TX 2000/08 138 TX 851 TX 852 TX Texas 90 TX Texas Personal Auto Application 137 TX 290 TX 2010/06 2010/06 853 TX 2014/01 854 TX 2012/08 855 TX 2015/02 Tennessee Personal Auto Application Tennessee Commercial Auto Tennessee Garage and Dealers Tennessee Personal Automobile Application Section Texas Liability Insurance Card Texas Consumer Bill of Rights for Personal Auto Texas Consumer Bill of Rights for Personal Auto (Spanish) Texas Windstorm Insurance Association Application Texas Homeowners and Personal Property - Rights Texas Homeowners and Personal Property - Rights (Spanish) Texas Special Mobile Home Windstorm/Haill Application Texas Commercial Auto Texas Garage and Dealers Texas Personal Automobile Application Section TX Personal Lines Supp. - Use of Credit Information Disclosure TX Personal Lines Supp. (Spanish Version) - Use of Credit Information Disclosure Texas Personal Property Supplement Texas Risk Pool Certificate of Property Coverage Texas Risk Pool Certificate of Liability Coverage Page 9 of 12
62 VA 6/97 Virginia 38 VA 2011/05 Virginia Notice of Information Practices (Privacy) 60 VA 8/94 Virginia Auto Supplement - Rental Reimbursement Coverage ACORD Forms Index Virginia Property Supplement Ordinance or Law Coverage; Additional Cov Available 64 VA 2005/01 Virginia Property Supplement - Notice of Flood Insurance 67 VA 2000/11 Virginia Property Insurance Association 90 VA Virginia Personal Auto Application STATE P&C FORMS - continued 61 UT 67 UT 10/94 Utah 63 UT 9/93 Utah Fraud Statement 66 UT 6/94 Utah Arbitration Provisions 90 UT 137 UT 138 UT 290 UT 2013/04 United States 60 US Insurance Supplement - Offer of Terrorism Coverage 62 US 64 US 50 VT 2007/02 66 VT 90 VT 137 VT 138 VT 290 VT 51 UT 2014/07 Insurance Supplement - Offer of Terrorism Coverage Standard Fire Policy Only Insurance Supplement - Offer of Terrorism Coverage Workers Compensation Utah Auto Supplement Uninsured / Underinsured Motorist Coverage Selection Utah Auto Supplement PIP Coverage, Loss of Income Waiver Utah Personal Auto Application Utah Commercial Auto Utah Garage and Dealers Utah Personal Auto Application Section Vermont 2003/06 Vermont Insurance Supplement - Fair Credit Reporting Act Utah Insurance Identification Card Vermont Automobile Insurance Identification Card Vermont Personal Auto Application Vermont Commercial Auto Vermont Garage and Dealers Vermont Personal Auto Application Section Virgin Islands 90 VI Virgin Islands Personal Auto Application 137 VI 2014/08 Virgin Islands Commercial Auto 138 VI 2015/06 Virgin Islands Garage and Dealers 290 VI Virgin Islands Personal Auto Application Section 38 WV 50 WV 60 WV 61 WV 62 WV 64 WV 65 WV 65 PA / DE / WV 66 WV 67 68 WV 90 WV 137 WV 138 WV 290 WV 862 WV 97 WI 2003/10 Wisconsin 4 WI 2003/04 Wisconsin Employers First Report of Injury or Disease 90 WI Wisconsin Personal Auto Application 133 WI 2010/04 Wisconsin Workers Compensation Insurance Pool 134 WI 8/99 Wisconsin Supplementary Non-Election Form 135 WI 8/99 Wisconsin Supplementary Election of Coverage Form 136 WI Wisconsin Supplement Limited Other States Coverage Request 137 WI Wisconsin Commercial Auto 138 WI Wisconsin Garage and Dealers 177 WI 2006/04 2014/01 12/93 2012/04 2012/04 2006/05 2012/04 2015/07 2012/04 2005/07 2010/04 2011/11 2016/01 2016/01 2016/01 2016/01 2016/01 2016/01 West Virginia West Virginia Personal Insurance Supplement Notice of Insurance Information Practices West Virginia Certificate of Insurance West Virginia Auto Supplement - UM / UIM Vehicle Coverage West Virginia Auto Supplement - UM / UIM Coverage Offer Split Limits West Virginia Auto Supplement - UM / UIM Coverage Offer Single Limits West Virginia Essential Property Insurance Association Basic Property Insurance Application West Virginia Umbrella Liability Supplement Important Notice FAIR Plan Supplementary Questionnaire West Virginia Personal and Commercial Umbrella Liability Supplement - UM / UIM Coverage - Offer of Split Limits Illinois / Indiana / Kentucky / West Virginia Mine Subsidence Property Insurance Supplement West Virginia Umbrella Liability Supplement UM / UIM Coverage - Offer of Single Limits West Virginia Personal Auto Application West Virginia Commercial Auto West Virginia Garage and Dealers West Virginia Personal Auto Application Section West Virginia Property Supplement - Notice of Flood Coverage Exclusion Wisconsin Automobile Insurance Plan Private Passenger Auto Application Wisconsin Automobile Insurance Plan Business Auto Application 178 WI 2011/11 Wisconsin Automobile Insurance Plan - Truckers Application 137 VA Virginia Commercial Auto 138 VA Virginia Garage and Dealers 290 VA Virginia Personal Auto Application Section Washington 90 WA Washington Personal Auto Application 137 WA Washington Commercial Auto 290 WI Wisconsin Personal Auto Application Section Wyoming 90 WY Wyoming Personal Auto Application 137 WY Wyoming Commercial Auto 138 WY Wyoming Garage and Dealers 290 WY Wyoming Personal Auto Application Section 138 WA Washington Garage and Dealers 290 WA Washington Personal Auto Application Section Page 10 of 12
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 ACORD Forms Index ACORD Australia Forms - Available ONLY on the ACORD Web Site AUSTRALIA FORMS Number Edition Title Page 11 of 12
Number Edition ACORD Forms Index ACORD Life/Annuity/Health Forms - Available ONLY on the ACORD Web Site COUNTRYWIDE LIFE FORMS Title Number Edition Title 650 Authorization for the Release of Health Information 794 2012/01 Request for Proposal - Dental and Vision Supplement 651 2007/07 Electronic Funds Transfer Authorization Form for Long Term Care Insurance 821 Producer Information Form (PIF) 652 2007/07 Credit Card Payment Authorization Form for Long Term Care Insurance 951 1035 Exchange / Rollover / Transfer Form 653 2008/04 Policy Delivery Receipt 731 2010/05 Request for Proposal - Additional Unions Schedule 732 2010/05 Request for Proposal - Additional Locations Schedule 733 2010/05 Request for Proposal - Additional Covered Affiliates Schedule 752 2004/01 Illustration Certification and Acknowledgement 759 2007/03 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 Number Edition Title Arkansas 966 AR 2007/03 Arkansas Annuity Product Comparison Form California 757 CA 2004/07 California HIV Antibody/Antigen Consent and Testing Form STATE LIFE FORMS Number Edition Title New York 751 NY New York Authorization to Obtain and Disclose Information 753 NY New York Notice of Insurance Information Practices (Pre Notice) 757 NY New York HIV Antibody/Antigen Consent and Testing Form 760 CA 2015/06 California Notice Regarding Replacement 966 CA 2007/03 California Annuity Product Comparison Form 757 DC 2004/07 District of Columbia District of Columbia HIV Antibody/Antigen Consent and Testing Form Florida 757 FL 2005/03 Florida HIV Antibody/Antigen Consent and Testing Form 759 FL 2005/06 Florida Notice to Applicant Regarding Replacement of Life Insurance 966 FL 2007/03 Florida Annuity Product Comparison Form 969 FL 2007/03 Florida Annuity Product Comparison Form Supplement - Policy / Rider Description Hawaii 759 HI 2007/03 Hawaii Important Notice Regarding Replacement Idaho 760 ID 2007/03 Idaho Important Notice Regarding Replacement Maryland 759 MD 2005/06 Maryland Important Notice Regarding Replacement Massachusetts 757 MA 2004/11 Massachusetts HIV Antibody/Antigen Consent and Testing Form 760 MA 2015/06 Massachusetts Important Notice Regarding Replacement Michigan 760 NY 775 NY 2007/03 2007/03 New York Important Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts New York Disclosure Statement Regarding Replacement of Life Insurance Policies or Annuity Contracts 776 NY 2007/03 New York Definition of Replacement 960 NY 2007/03 New York Disclosure Statement Annuity to Annuity Replacements Only Ohio 757 OH 2009/02 Ohio HIV Antibody/Antigen Consent and Testing Form Oregon 757 OR 2004/07 Oregon HIV Antibody/Antigen Consent and Testing Form Rhode Island 766 RI 2007/03 Rhode Island Life Product Comparison Form Texas 757 TX 2004/11 Texas HIV Antibody/Antigen Consent and Testing Form 759 TX 2008/02 Texas Important Notice: Replacement of Life Insurance or Annuities Virginia 655 VA 2010/12 Virginia Group Health Insurance - Medical History Form Washington 757 WA 2010/05 Washington HIV Antibody/Antigen Consent and Testing Form 760 WA 2015/06 Washington Important Notice Regarding Replacement 757 MI 2004/12 Michigan HIV Antibody/Antigen Consent and Testing Form Page 12 of 12