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Form # Edition Form Name 1 2002/01 Property Loss Notice 2 2003/11 Automobile Loss Notice 3 2002/01 General Liability Notice of Occur/Claim 4 WI 2003/04 Workers Compensation - Employers 1st Rep 4 2001/02 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 25 2001/08 Certificate of Liability Insurance 26 2002/01 Certificate Log 27 2003/10 Evidence of Personal Property Insurance 28 2003/10 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 38 2003/09 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 40 2003/01 Residential Property Valuation Survey 41 1/98 Residential Prop Replacement Cost Wkst 42 2001/05 Residential Property Replacement Cost 45 2003/04 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
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 60 2002/09 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
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 63 2001/10 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
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. 67 2001/07 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)
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 70 2003/09 Personal Policy Change Request (Except Auto) 71 SC 2003/03 Associated Auto Ins Plan of SC - Private Passenger Policy Change Request 71 2003/09 Personal Auto Policy Change Request 72 2002/12 Certification of Mobile Homes Tie-downs Supplement 73 2000/08 Solid Fuel Questionnaire 74 2001/05 Residence Based Business 75 2001/01 Insurance Binder 76 9/93 Binder Log 78 2003/04 Jewelry Insurance Appraisal - Single Item 79 2003/04 Jewelry Insurance Appraisal 80 2003/09 Homeowner 81 2002/09 Personal Inland Marine 82 2002/09 Watercraft 83 2003/09 Personal Umbrella 84 2003/09 Dwelling Fire 85 2003/09 Mobile Home 86 2003/09 Personal Lines Package 87 2003/06 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
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 93 2003/01 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 125 2003/01 Commercial Insurance Applicant Information Section 126 2003/07 Commercial General Liability Section 127 2003/08 Business Auto Section 128 2003/05 Garage and Dealers Section 129 SC 2003/03 Assoc Ins Plan of SC - Vehicle Schedule 129 2003/08 Vehicle Schedule 130 FL 2002/07 Florida Workers Comp 130 2003/10 Workers Compensation 131 2003/08 Umbrella Section 132 NJ 2000/04 NJ Workers Compensation Insurance Plan Instructions/Rules 132 2003/05 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 133 2003/10 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
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
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 139 2000/07 Statement/Schedule of Values 140 2002/09 Property Section 141 C 2002/12 Crime Section 2000 141 2003/07 Crime Section 143 9/91 Transportation Section 144 11/94 Glass And Sign Supplement 145 2003/08 Accounts Receivable/Valuable Papers 146 2003/09 Equipment Floater 147 2001/02 Installation/Builder s Risk 148 2000/02 Electronic Data Processing 149 2000/02 Dealers Section 151 2001/07 Miscellaneous Crime Coverage Section 154 1/98 Jeweler s Inventory Record-Keeping Card 155 2000/11 Boiler & Machinery 155 BM 2003/08 Boiler & Machinery Section 2002 159 2000/07 Schedule of Insurance 160 2003/03 Business Owners 163 2000/11 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
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 14 171 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 175 2003/08 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
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 185 2003/07 Restaurant/Tavern Supplement 186 SC 2003/03 Assoc Auto Ins Plan - Unin/Under Cvge for Comm Risks 186 2001/09 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 188 2003/02 Employment Related Practices Liability Section 190 1/96 Supplemental Property 192 7/98 Equine Insurance 193 2001/02 Open Cargo Section 194 2001/05 Truckers/Motor Carrier Supplement 195 10/96 Design Professional s Ind. Prop. Survey 196 2000/08 Medical Professional Liability Insurance App. 199 1/99 Supplement - Undertaking 200 3/93 Producer Account 201 3/93 Producer Account Discrepency Notice 210 2001/05 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 303 2003/07 Flood Ins. Preferred Risk Policy App. 304 3/97 Flood Ins. Cancellation/Nullification 325 2006/05 Aviation Insurance - Applicant Information Section 331 2006/04 Pilot Experience 351 2000/02 NAIC Uniform App. for Individual Non- Resident License
352 2000/02 NAIC Uniform App. for Business Entity Non-Resident License/Registration 401 2001/10 Agriculture 402 2001/10 Agriculture Property Section 403 2000/05 Agri-Business Property Section 404 2000/05 Agri-Business Liability Section 405 2000/05 Agriculture Premises Diagram 410 2001/05 Small Farm/Ranch 501 2001/02 Surety Report of Execution 610 2003/09 Premium Payment Supplement 801 2002/01 Railroad Protective Liability Supplement 802 2002/01 Hotel/Motel Supplement 805 2002/12 Jewelry Sales Receipt for Insurance Purposes 851 SC 2003/03 Assoc Auto Ins Plan of SC - Electronic App Submission Interface Retraction Request Form