ACORD Forms Notification Service November 2009 Bulletin

Transcription

1 ACORD Forms Notification Service November 2009 Bulletin ACORD P&C and Life/Annuity/Health Form Changes and Additions The following pages include both a List of recently Revised and New ACORD forms and an Explanation of the Changes made. Copies of the forms mentioned in this announcement can be downloaded in the formats you need at either of these two web sites: > > ACORD Forms > Download Forms, or > > Forms > Forms Search To download forms, you will need to sign-in as an ACORD or ACORD Advantage member with your user name and password. If you need assistance, a sample of a form, or are an agent/broker who would like to join the Advantage Program, please call Member Services at (800) , Option 2 or us at MemberServices@acord.org. If you do not wish to receive this notification, please send an to memberservices@acord.org requesting that we unsubscribe you to this Forms Notification Service. Form Enhancements This month, ACORD will be releasing several forms with new features and enhancements. Note: These are not new forms editions. The forms have not changed, nor have any fields been added or removed. The enhancements involve forms use and include: Field Parsing: Data fields such as Address are now separated into component parts (street, city, state, zip), to allow for more precise data capture and more accurate transmission. Improved FIGs: ACORD's Forms Instruction Guides are integrated into the forms to provide specific help for each field on screen, and are consistent across all forms. Overflow Capability: Fields and lists can be configured to expand to meet your requirements for additional information. Forms (By Number) for November AL 62 IA 62 IL 62 MI 62 MN 62 MO 62 NJ 62 PA 62 TX 62 WV ACORD Forms Notification

2 ACORD Forms Release Form Number Replaces Title REVISIONS P&C - Countrywide 74 (2009/09) 2008/07 Residence Based Business Supplement to Residential Section P&C-State Specific 65 NC (2010/02) 2009/01 North Carolina Auto Supplement (Regulatory requirement, effective February 1, 2010) 90 NC (2010/02) 2009/04 North Carolina Personal Auto Application Section (Regulatory requirement, effective February 1, 2010) 90 NE (2010/01) 2003/12 Nebraska Personal Auto Application Section (Regulatory requirement, effective January 1, 2010) 95 MA (2009/12) 2007/08 Massachusetts Renewal Form 137 NC (2010/02) 2007/06 North Carolina Commercial Auto Coverages / Limits Section (Regulatory requirement, effective February 1, 2010) 137 NE (2010/01) 2001/10 Nebraska Commercial Auto Coverages / Limits Section (Regulatory requirement, effective January 1, 2010) 138 NC (2010/02) 2007/06 North Carolina Garage and Dealers Coverages / Limits Section (Regulatory requirement, effective February 1, NE (2010/01) 8/97 Nebraska Garage and Dealers Coverages / Limits Section (Regulatory requirement, effective January 1, 2010) Life/Annuity/Health NEW P&C - Countrywide P&C State Specific Life/Annuity/Health WITHDRAWN * Due to their unique nature, printed versions of ACORD forms identified with an asterisk (*) will not be available for shipping for business days. You can download forms from the ACORD Web site immediately. 1 of 1 ACORD Forms Release

3 Countrywide Revised P&C FORMS 74 (2009/09) Residence Based Business Page 1 1. Redesign IDENTIFICATION section: a. Add Effective Date field to the right of Policy Number field b. Move CARRIER and NAIC CODE fields to top right above NAMED INSURED field c. Increase Carrier label font to 8 pt bold d. Add (S) to NAMED INSURED label 2. LIABILITY COVERAGES section, add additional blank row. Total blank rows is three. 3. GENERAL INFORMATION section, Question 3, create tabular format with fields for NAIC CODE, CARRIER and POLICY NUMBER 4. Revise ACORD copyright to Delete INITIALS field Page 2 6. GENERAL INFORMATION (continued) section, break out Question 5 into two separate questions and re-number remaining questions 7. GENERAL INFORMATION (continued) section, new Question 5, create tabular format with fields for PARENT COMPANY NAME and DESCRIPTION 8. GENERAL INFORMATION (continued) section, new Question 6, create tabular format with fields for SUBSIDIARY COMPANY NAME and DESCRIPTION 9. REMARKS section, reduce height and add (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 10. Delete INITIALS field State Specific Revised 65 NC (2010/02) North Carolina Auto Supplement 1. Add EFFECTIVE DATE field to IDENTIFICATION section 2. Replace first paragraph with new text 3. Second paragraph, add and property damage to THIS INSURANCE PROTECTS YOU AND YOUR FAMILY AGAINST INJURIES AND PROPERTY DAMAGE etc. 4. Add new paragraphs 3, 4 and 5 5. Delete old paragraph three 6. Revise NC form number to: NCRB NC Revise ACORD copyright to 2009, of 12 ACORD Explanation of Changes

4 90 NC (2010/02) North Carolina Personal Auto Application Section Page 1 1. VEHICLE / DESCRIPTION USE section, Move CLASS column to the third row of data, two fields each to the right of both VEH column. Resize columns and reformat labels to fit. 2. VEHICLE / DESCRIPTION USE section, add two new columns to the right of SYMBOL AGE GRP column labeled COMP OTC SYM and COLL SYM, move remaining columns to the right. 3. Update ACORD copyright dates to Page 2 4. ACCIDENTS / CONVICTIONS section, Revise heading to: Attach, ACORD 99, Additional Accidents / Convictions Schedule, if more space is required Page 3 5. SIGNATURE section, first paragraph, update NOTICE OF INFORMATION PRACTICES to standard notice which references Credit Scoring 6. SIGNATURE section, third paragraph, update Uninsured Motorist and Underinsured Motorist disclosure 90 NE (2010/01) Nebraska Personal Auto Application Section This application section must be used in conjunction with ACORD 88, Personal Insurance Application. Page 1 1. Add field for Agency Customer ID to the upper right hand corner 2. Revise title of form to NEBRASKA PERSONAL AUTO APPLICATION SECTION (14 pt bold font) 3. Revise IDENTIFICATION SECTION, fields now include AGENCY, POLICY NUMBER, EFFECTIVE DATE, NAMED INSURED(S), CARRIER and NAIC CODE 4. Move PRODUCER LICENSE # and AGENCY STATE LICENSE # fields to SIGNATURE section on page 3 5. Delete RESIDENCE section, (on ACORD 88) 6. Revise GARAGING ADDRESS section, fields now include LOC, VEH, STREET, CITY, COUNTY, STATE and ZIP Add extra spaces around slash (/) in VEHICLE / DESCRIPTION USE section title 8. VEHICLE / DESCRIPTION USE section, create separate columns for MAKE, MODEL, BODY TYPE, VIN and REG STATE 9. VEHICLE / DESCRIPTION USE section, Move CLASS column to the third row of data, two fields each to the right of both VEH column. Resize columns and reformat labels to fit. 10. VEHICLE / DESCRIPTION USE section, add two new columns to the right of SYMBOL AGE GRP column labeled COMP OTC SYM and COLL SYM, move remaining columns to the right. 11. Add extra spaces around slash (/) in COVERAGES / PREMIUMS section title 12. COVERAGES / PREMIUMS section, add / OTC to COMPREHENSIVE label 13. COVERAGES / PREMIUMS section, ACV UNLESS AMOUNT STATED row, delete dollar signs ($) in last four PREMIUM columns and replace with N / A 2 of 12 ACORD Explanation of Changes

5 90 NE (2010/01) Nebraska Personal Auto Application Section (continued) 14. COVERAGES / PREMIUMS section, add extra spaces around slash (/) in TRANS EXP / RENTAL RE label 15. COVERAGES / PREMIUMS section, delete all rows below TRANS EXP / RENTAL RE row and add seven new blank coverages rows. Retain ESTIMATED TOTAL, POLICY FEE and TOTAL PER VEHICLE fields 16. Move RESIDENT & DRIVER INFORMATION and ACCIDENTS/ CONVICTIONS sections to Page Revise PLEASE COMPLETE REVERSE SIDE to Page 1 of Revise ACORD copyright to with the years as the first item after the copyright symbol and add All rights reserved. 19. Add Attach to ACORD 88 to footer 20. Add The ACORD name and logo are registered marks of ACORD Page Add field for Agency Customer ID to the upper right hand corner 22. RESIDENT & DRIVERS INFORMATION section, redesign section to the same type of formatting as the VEHICLE DESCRIPTION / USE section. Data for one DRIVER will now be captured in two rows instead of one. Split out NAME (AS IT APPEARS ON LICENSE) fields and DRIVERS LICENSE # and LIC STATE fields. Section now captures data for six drivers. 23. Add extra spaces around slash (/) in ACCIDENTS / CONVICTIONS section title 24. ACCIDENTS / CONVICTIONS section, revise text in parentheses and add: Attach, ACORD 99, Additional Accidents / Convictions Schedule, if more space is required 25. ACCIDENTS / CONVICTIONS section, in text above the table, delete YES / NO check boxes and replace with a single field to capture a Y or N response, reformat text. Redesign BI OR DEATH column to a single column/field to capture a Y or N response. Section now captures data for five Accident / Convictions. 26. Delete ADDITIONAL INTEREST, EMPLOYMENT INFORMATION and PRIOR COVERAGE sections. That is contained in ACORD GENERAL INFORMATION section, reformat questions with space and/or table below to capture explanation, with questions going across the entire page. Replace YES/NO columns with one column labeled Y / N. Check boxes replaced with a single filed to capture Y for a YES response and N for a NO response 28. GENERAL INFORMATION section, delete Questions 5, 6, 8 and 13 and re-number remaining questions. 29. GENERAL INFORMATION section, Question 1, add table with fields to capture VEH # and NAME OF OTHER OWNER 30. GENERAL INFORMATION section, Question 2, add table with fields to capture VEH #, DESCRIPTION and COST $ 31. GENERAL INFORMATION section, Question 3, add table with fields to capture VEH # and DESCRIPTION 32. GENERAL INFORMATION section, Question 4, add table with fields to capture DRV #, DESCRIPTION and COST $ 33. GENERAL INFORMATION section, Question 5, add table with fields to capture NAMED INSURED, YEAR, MAKE, MODEL, CARRIER, NAIC # and POLICY # 3 of 12 ACORD Explanation of Changes

6 90 NE (2010/01) Nebraska Personal Auto Application Section (continued) 34. GENERAL INFORMATION section, Question 6, add table with fields to capture DRV #, BRANCH, RANK, BASE LOCATION and VEH AT BASE ( Y / N) 35. GENERAL INFORMATION section, Question 7, add table with fields to capture DRV #, SUSPENSION PERIOD (Start Date: and End Date:), EXPLANATION and REINSTATEMENT DATE 36. GENERAL INFORMATION section, Question 8, add table with fields to capture DRV #, DESCRIPTION OF SPECIAL EQUIPMENT and MEDICATION / TREATMENT 37. GENERAL INFORMATION section, Question 9, add table with fields to capture DRV #, REASON FOR FILING and FILING DATE 38. GENERAL INFORMATION section, Question 10, add table with fields to capture DRV #, REASON, DECLINED, CANCELLED OR NON-RENEWED 39. Add Page 2 of 3 to footer Page Add field for Agency Customer ID to the upper right hand corner 41. Add new section GENERAL INFORMATION (continued) beginning with re-numbered Question GENERAL INFORMATION (continued) section, add new Question 13, with a table to capture fields for DRV # and EXPLANATION 43. Revise REMARKS section to REMARKS / ATTACHMENTS section, add (Attach ACORD 101, Additional Remarks Schedule, if more space is required) to header 44. REMARKS / ATTACHMENTS section, reformat and delete FOR COMPANY USE ONLY. There are now four blank attachment check boxes with fields for descriptions 45. Rename BINDER/SIGNATURE section to SIGNATURE 46. SIGNATURE section, delete BINDER information. That is contained in ACORD 88. First item in SIGNATURE section is NOTICE OF INFORMATION PRACTICES 47. SIGNATURE section, all increase font to 9 pt 48. SIGNATURE section, update NOTICE OF INFORMATION PRACTICES 49. SIGNATURE section, add Fraud Warning immediately below Notice of Information Practices 50. SIGNATURE section, reformat actual signature fields. Add field for PRODUCER S NAME, PRODUCER STATE LICENSE # and AGENCY STATE LICENSE # 51. Add Page 3 of 3 to footer 4 of 12 ACORD Explanation of Changes

7 95 MA (2009/12) Massachusetts Renewal Form Page 1 1. IDENTIFICATION section, add brackets to PRODUCER label 2. First paragraph below the IDENTIFCATION section, revise the word YOUR to YOU in the coverages you have purchased, and add additional text to the second paragraph 3. VEHICLE INFORMATION section revise Item 3 to: Principally garaged in: 4. DRIVER INFORMATION section, text immediately above table, revise Operator Status to operator status (all lower case) 5. DRIVER INFORMATION section, last paragraph, bold the word NOTICE and add a new first sentence to the paragraph 6. Revise copyright years to Page 2 7. DRIVER INFORMATION (continued) section, first paragraph, last sentence, revise the Safe Driver Insurance Plan to: a merit rating plan 8. DRIVER INFORMATION (continued) section, Items (A) and (B), make all text lower case 9. DRIVER INFORMATION (continued) section, last paragraph, first sentence, revise SDIP points to: merit rating points 10. DISCOUNTS section, delete all text except for the first and last sentence and reduce size of section 11. ADDITIONAL INFORMATION section, expand area 12. Revise form number to MA AIB RENEWAL FORM, NC (2010/02) North Carolina Commercial Auto Coverages / Limits Section Page 1 1. Add extra spaces around slash (/) in subtitle COVERAGES / LIMITS SECTION 2. Replace IDENTIFICATION SECTION with the new standard format for an auto section. Fields included are: AGENCY, POLICY NUMBER, EFFECTIVE DATE, NAMED INSURED(S), CARRIER and NAIC CODE 3. BUSINESS AUTO section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES except LIABILITY (blank check box already there). 4. BUSINESS AUTO section, left COVERAGES column, add extra spaces around slash (/) in HIRED / BORROWED LIABILITY label 5. BUSINESS AUTO section, NON-OWNED LIABILITY row delete the two blank check boxes immediately below the YES / NO check boxes 6. BUSINESS AUTO section, PHYSICAL DAMAGE sub-section, revise sentence with asterisk to: * Include the Fire District name and code # if fire or COMP / OTC coverage is provided 7. BUSINESS AUTO section, HIRED PHYSICAL DAMAGE row, add extra spaces around slash (/) in COVERAGE / DEDUCTIBLE label 8. Add (Attach ACORD 101, Additional Remarks Schedule, if more space is required) to ENDORSEMENTS / REMARKS section title 9. Add new SIGNATURE section 5 of 12 ACORD Explanation of Changes

8 137 NC (2010/02) North Carolina Commercial Auto Coverages / Limits Section (continued) 10. Revise ACORD copyright to , using new format where the years are the first item after the copyright symbol Page TRUCKERS section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES except TRAILER INTERCHANGE section. Realign check boxes to fit. Right column rows increased in height as well. 12. TRUCKERS section, LIABILITY row, reformat COVERED AUTO SYMBOLS check boxes and delete blank row below 13. TRUCKERS section, left COVERAGES column, add extra spaces around slash (/) in UNINSURED / UNDERINSURED MOTORIST, NON-TRUCKERS HIRED / BORROWED and TRUCKERS HIRED / BORROWED LIABILITY labels 14. TRUCKERS section, NON-OWNED LIABILITY row delete the two blank check boxes immediately below the YES / NO check boxes 15. TRUCKERS section, expand height of OTHER row and add two additional blank rows 16. TRUCKERS section, PHYSICAL DAMAGE sub-section, revise sentence with asterisk to: * Include the Fire District name and code # if fire or COMP / OTC coverage is provided 17. TRUCKERS section, TRAILER INTERCHANGE sub-section, revise sentence with asterisk to: * Include the Fire District name and code # if fire or COMP / OTC coverage is provided 18. Add (Attach ACORD 101, Additional Remarks Schedule, if more space is required) to ENDORSEMENTS / REMARKS section title 19. Add new SIGNATURE section Page MOTOR CARRIER section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES except TRAILER INTERCHANGE section 21. MOTOR CARRIER section, left COVERAGES column, add extra spaces around slash (/) in UNINSURED / UNDERINSURED MOORIST, NON-TRUCKERS HIRED / BORROWED and TRUCKERS HIRED / BORROWED LIABILITY labels 22. MOTOR CARRIER section, NON-OWNED LIABILITY row delete the two blank check boxes immediately below the YES / NO check boxes 23. MOTOR CARRIER section, PHYSICAL DAMAGE sub-section, revise sentence with asterisk to: * Include the Fire District name and code # if fire or COMP / OTC coverage is provided 24. MOTOR CARRIER section, TRAILER INTERCHANGE sub-section, revise sentence with asterisk to: * Include the Fire District name and code # if fire or COMP / OTC coverage is provided 25. Add (Attach ACORD 101, Additional Remarks Schedule, if more space is required) to ENDORSEMENTS / REMARKS section title 26. Redesign new SIGNATURE section 27. SIGNATURE section, revise first paragraph, Notice of Insurance Information Practices (consistency between 137s) 28. SIGNATURE section, add notice regarding Uninsured Motorist and Underinsured Motorist coverages immediately following the second paragraph 6 of 12 ACORD Explanation of Changes

9 137 NE (2010/01) Nebraska Commercial Auto Coverages / Limits Section Please Note: This form is now three pages. Page 1 1. Add field for AGENCY CUSTOMER ID: to top right hand corner 2. Replace logo 3. Delete border around title and center 4. Add extra spaces around slash (/) in subtitle COVERAGES / LIMITS SECTION 5. Replace IDENTIFICATION SECTION with the new standard format for an auto section. Fields included are: AGENCY, POLICY NUMBER, EFFECTIVE DATE, NAMED INSURED(S), CARRIER and NAIC CODE 6. BUSINESS AUTO section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES except LIABILITY (blank check box already there). 7. BUSINESS AUTO section, left COVERAGES column, add extra spaces around slash (/) in HIRED / BORROWED LIABILITY label 8. BUSINESS AUTO section, PHYSICAL DAMAGE sub-section, revise COMPREHENSIVE to COMP / OTC 9. BUSINESS AUTO section, HIRED PHYSICAL DAMGE row, add extra spaces around slash (/) in COVERAGE / DEDUCTIBLE label 10. Move TRUCKERS section to top of page Add new ENDORSEMENTS / REMARKS section 12. Add new SIGNATURE section from revised page Revise ACORD copyright to , using new format where the years are the first item after the copyright symbol. Add All rights reserved. 14. Revise Please complete reverse side to Page 1 of 3 in footer 15. Add The ACORD name and logo are registered marks of ACORD Page Add field for AGENCY CUSTOMER ID: to top right hand corner 17. TRUCKERS section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES except TRAILER INTERCHANGE section. Realign check boxes to fit. Right column rows increased in height as well. 18. TRUCKERS section, left COVERAGES column, add extra spaces around slash (/) in NON-TRUCKERS HIRED / BORROWED label and add TRUCKERS to HIRED / BORROWED LIABILITY label 19. TRUCKERS section, expand height of OTHER row and add one additional blank row 20. TRUCKERS section, PHYSICAL DAMAGE sub-section, revise COMPREHENSIVE to COMP / OTC 21. TRUCKERS section, TRAILER INTERCHANGE sub-section, revise COMPREHENSIVE to COMP / OTC and revise STATE to FARTH ZONE 22. Add new ENDORSEMENTS / REMARKS section 23. Add new SIGNATURE section from revised page Add Page 2 of 3 to footer 25. MOTOR CARRIER section is now page 3 Page Add field for AGENCY CUSTOMER ID: to top right hand corner 27. MOTOR CARRIER section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES except TRAILER INTERCHANGE section. Realign check boxes to fit. 7 of 12 ACORD Explanation of Changes

10 137 NE (2010/01) Nebraska Commercial Auto Coverages / Limits Section (continued) 28. MOTOR CARRIER section, left COVERAGES column, add extra spaces around slash (/) in NON- TRUCKERS HIRED / BORROWED label and add TRUCKERS to HIRED / BORROWED LIABILITY label 29. MOTOR CARRIER section, PHYSICAL DAMAGE sub-section, revise COMPREHENSIVE to COMP / OTC 30. MOTOR CARRIER section, TRAILER INTERCHANGE sub-section, revise COMPREHENSIVE to COMP / OTC and revise STATE to FARTH ZONE 31. Revise ENDORSEMENTS section title to ENDORSEMENTS / REMARKS and add (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 32. Add SIGNATURE section 33. SIGNATURE section, Notice of Insurance Information Practices, delete including information from a credit report and add the letter S to the word INSTRUCTIONS in the last sentence 34. SIGNATURE section, add Fraud Warning immediately below Notice of Information Practices 35. SIGNATURE section, reformat Signatures and add a field labeled NATIONAL PRODUCER NUMBER 36. Add Page 3 of 3 to footer 8 of 12 ACORD Explanation of Changes

11 138 NC (2010/02) North Carolina Garage and Dealers Coverages / Limits Section Please note: This form is now two pages Page 1 1. Add extra spaces around slash (/) in COVERAGES / LIMITS SECTION subtitle 2. Replace IDENTIFICATION SECTION with the new standard format for an auto section. Fields included are: AGENCY, POLICY NUMBER, EFFECTIVE DATE, NAMED INSURED(S), CARRIER and NAIC CODE 3. Add extra spaces around slash (/) in COVERAGES / LIMITS section header 4. COVERAGES / LIMITS section title, add APPLIES TO: and check box options for AUTOMOBILE and PREMISES OPERATIONS. These check boxes had been in the Limits of Liability column in the first row on the right. 5. COVERAGES / LIMITS section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES 6. COVERAGES / LIMITS section, add extra spaces around slash (/) in UNINSURED / UNDERINSURED MOTORIST 7. PHYSICAL DAMAGE sub-section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES and reformat COLLISION row to fit blank check box. 8. GARAGE KEEPERS sub-section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES 9. Make ENDORSEMENTS/REMARKS its own section and add an asterisk. Revise sentence with asterisk to: * Include the Fire District name and code # if fire or COMP / OTC coverage is provided above, and move into rectangled area 10. Move Notices and Signatures to page Add Page 1 of 2 to footer 12. Revise ACORD copyright to , using new standard format where the years are the first item after the copyright symbol. Page Add field for AGENCY CUSTOMER ID: to top right hand corner 14. Add ENDORSEMENTS/REMARKS section 15. Add SIGNATURE section 16. SIGNATURE section, add notice regarding Uninsured Motorist and Underinsured Motorist coverages immediately following the second paragraph 9 of 12 ACORD Explanation of Changes

12 138 NE (2010/01) Nebraska Garage and Dealers Coverages / Limits Section 1. Add field for AGENCY CUSTOMER ID: to top right hand corner 2. Replace logo 3. Delete border around title and center 4. Add extra spaces around slash (/) in COVERAGES / LIMITS SECTION subtitle 5. Replace IDENTIFICATION SECTION with the new standard format for an auto section. Fields included are: AGENCY, POLICY NUMBER, EFFECTIVE DATE, NAMED INSURED(S), CARRIER and NAIC CODE 6. Add extra spaces around slash (/) in COVERAGES / LIMITS section header 7. COVERAGES / LIMITS section title, add APPLIES TO: and check box options for AUTOMOBILE and PREMISES OPERATIONS. These check boxes had been in the Limits of Liability column in the first row on the right. 8. COVERAGES / LIMITS section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES 9. COVERAGES / LIMITS section, LIABILITY row, revise EA ACCIDENT to EA ACC and move dollar signs to the left to increase field sizes 10. PHYSICAL DAMAGE sub-section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES and reformat COLLISION row to fit blank check box. 11. GARAGE KEEPERS sub-section, COVERERED AUTO SYMBOLS columns, add a blank check box for all COVERAGES 12. Delete ENDORSEMENTS/REMARKS section and add statement: ENDORSEMENTS / REMARKS (Attach ACORD 101, Additional Remarks Schedule, for any endorsements or remarks) 13. Add SIGNATURE section 14. SIGNATURE section, Notice of Insurance Information Practices, add in connection with this application for insurance and subsequent renewals at the end of the first sentence and add the letter S to the word INSTRUCTIONS in the last sentence 15. SIGNATURE section, add Fraud Warning immediately below Notice of Information Practices 16. SIGNATURE section, reformat Signatures and add a field labeled NATIONAL PRODUCER NUMBER Countrywide New State Specific New WITHDRAWN FORMS 10 of 12 ACORD Explanation of Changes

13 LIFE / ANNUITY / HEALTH FORMS Countrywide - Revised State Specific - Revised Countrywide - New State Specific - NEW WITHDRAWN FORMS 11 of 12 ACORD Explanation of Changes

14 STATE ACTIVITY South Dakota DOI - Notice of Extension to Comply with Bulletins and The South Dakota Department of Insurance (DOI) issued a Notice of Extension to Comply with Bulletins and 09-06, November 23, The Memorandum provides software vendors with additional time to implement the recently revised ACORD 24 and ACORD 25 Certificates of Insurance forms into their systems. All licensees must comply by January 15, Please see the below South Dakota DOI Memorandum. Memorandum DATE: November 23, 2009 TO: All Property Casualty Insurers & Agents FROM: Merle Scheiber, Director RE: Notice of Extension to Comply with Bulletins and In a memorandum dated August 19, 2009, licensees were provided with an extension to comply with the provisions of Bulletins and until 11/1/09. While both ACORD and ISO have modified their certificates of insurance, not all vendors have implemented those changed forms into their software that is available for licensees. Therefore an additional extension is granted for licensees until January 15, There will be no further extensions for compliance with these bulletins. All licensees must be in compliance with Bulletins and by January 15, North Carolina revises the requirements for Uninsured and Underinsured Motorist coverage. North Carolina Senate Bill 749, effective February 01, 2010 revised the requirements for Uninsured and Underinsured Motorist coverage in motor vehicle liability insurance policies. (G.S ) ACORD will revise ACORD 90 NC, North Carolina Personal Auto Application Section, ACORD 137 NC, North Carolina Commercial Auto and 138 NC, North Carolina Garage and Dealers to comply with the new requirements. ACORD 65 NC, North Carolina Auto Supplement will also be revised. All four revised forms will be included in this release. Nebraska enacts insurance fraud law. ACORD countrywide forms not affected. Nebraska bill 1-LB 208 effective January 1, 2010 enacts an insurance fraud law. The law defines various kinds of insurance fraud, but does not require a specific fraud warning statement for applications or claim forms. Since ACORD s current standard fraud warning for Nebraska is covered by the new law, there will be no changes in ACORD countrywide forms due to this law. However, ACORD will revise the three Nebraska auto forms, 90 NE, Nebraska Personal Auto, 137 NE, Nebraska Commercial Auto and 138 NE, Nebraska Garage and Dealers to add the required fraud warning. Revised forms are included in this release. 12 of 12 ACORD Explanation of Changes