ACORD Forms Index. Street Address: City: State: Zip: Telephone: ACORD Account #: Address: Web Site: COUNTRYWIDE P&C FORMS

Transcription

1 Please provide the information below to avoid delay in shipment. Agency/Company Name: Contact Name: Street Address: City: State: Zip: Telephone: ACORD Account #: Fax: Address: Web Site: /10 Property Loss Notice /10 Automobile Loss Notice /10 Liability Notice of Occurrence / Claim /10 Workers Compensation First Report of Injury or Illness /10 Aircraft Loss Notice /05 Aviation Witness / Passenger Schedule /05 Aviation Injured Schedule 11 2/95 Auto Accident Information Form 12 2/95 Exchange of Information Form 13 2/95 Witness Card /03 Certificate of Aviation Liability /03 Certificate of Aircraft /03 Intermodal Interchange Certificate of /03 Vehicle or Equipment Certificate of /03 Certificate of Property /03 Certificate of Liability /01 Policy Certification Log /03 Evidence of Property /03 Evidence of Commercial Property /03 Evidence of Flood /03 Certificate of Garage /03 Certificate of Marine / Energy /05 Cancellation Request / Policy Release /01 Agent/Broker of Record Change /01 Statement of No Loss /01 Notice of Information Practices (Privacy) /08 Residential Property Replacement Cost /03 Additional Interest Schedule /02 Automobile ID Card /03 Automobile ID Card (with Watermark) WM 54 1/97 Financial Responsibility Form 57 1/97 Financial Responsibility Form Cancellation /11 Notice of Cancellation or Termination of Policy /04 Flood Selection / Rejection 60 US 2015/01 Supplement Notice Offer of Terrorism 62 US 2015/01 Supplement Standard Fire Policy Only Notice Offer of Terrorism /10 Fraud Statements 64 US 2015/01 Supplement Workers Compensation Only Notice Offer of Terrorism COUNTRYWIDE P&C FORMS /05 Personal Supplement - Extraordinary Life Circumstances /09 Personal Policy Change Request (Except Auto) /08 Personal Auto Policy Change Request /10 Mobile Home Supplement /07 Solid Fuel Questionnaire Supplement to Residential /09 Residence Based Business Supplement to Residential /03 Binder 76 9/93 Binder Log /11 Homeowner Application /03 Personal Inland Marine Application /03 Watercraft Application /04 Personal Umbrella Application /11 Dwelling Fire Application /11 Mobile Home Application /12 Personal Application Applicant Information /11 Residential /10 Good Student Driver Training /03 Medical Statement /08 Young Driver Questionnaire /02 Accidents / Convictions Schedule /01 Additional Remarks Schedule /03 Personal Auto Application Schedule Additional Resident and Driver Information /06 Apartment Building Supplement /04 Vacant Building Supplement /03 Commercial Application Applicant Information /09 Commercial General Liability /12 Business Auto /12 Garage and Dealers /11 Vehicle Schedule /05 Workers Compensation Application /11 Umbrella /12 Truckers / Motor Carriers /12 Workers Compensation Plan Assigned Risk /12 Statement / Schedule of Values /03 Property ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 1 of 13

2 /03 Crime /09 Transportation /09 Glass and Sign /09 Accounts Receivable / Valuable Papers /03 Installation / Builders Risk /03 Electronic Data Processing /09 Dealers /06 Commercial Inland Marine /09 Equipment Breakdown /09 Schedule of Property Limits /09 Business Owners /06 Commercial Auto Driver Information Schedule /03 Commercial Policy Change Request /03 Technology E&O Electronic Data Processors, Electric Products Manufacturers, Computer Services etc /09 Restaurant / Tavern Supplement /10 Contractors Supplement /03 Professional Liability Supplement /09 Supplemental Property Application /09 Open Cargo /03 Truckers / Motor Carrier Supplement /96 Design Professional s Individual Property Survey /09 Medical Professional Liability Application 199 1/99 Application Supplement Undertaking 200 3/93 Producer Account 201 3/93 Producer Account Discrepancy Notice /03 Yacht /09 Schedule of Hazards /09 Commercial Umbrella Underlying Schedule 225 1/98 Policyholder s Report 226 3/93 Statement of Premium Adjustment /03 Aviation Binder /03 Aircraft Binder /05 Personal Inland Marine /05 Watercraft /04 Personal Umbrella Application /04 National Flood Program Flood Application /04 NFIP Flood General Change Endorsement /04 NFIP Flood Preferred Risk Policy Application /04 NFIP Flood Cancellation / Nullification /02 NFIP Credit Card Payment Form /04 NFIP Rating Information and Elevated Building Determination Form /02 NFIP Floodproofing Certificate for Non-Residential Structures /04 NFIP Residential Basement Floodproofing Certificate /09 Aviation Application Applicant Information /04 Airport Property Supplement /03 Airport and FBO Liability /12 Private Hanger Liability /12 Aviation Products Liability /03 Aircraft /11 Pilot Experience /04 Hanger Schedule /05 Aircraft Schedule /06 Aviation Policy Change Request Applicant Information /06 Airport Property Change Request /03 Airport and FBO Liability Change Request /06 Private Hangar Liability Change Request /06 Aviation Products Liability Change Request /03 Aircraft Change Request /11 Pilot Experience Change Request COUNTRYWIDE P&C FORMS - continued /06 Hanger Change Request 350 Watermark Paper 20 # ID Card Stock (4-part perforation) 360 Watermark Paper 32 # ID Card Stock (4-part perforation) 370 Watermark Paper 32 # ID Card Stock (nonperforated) /03 Agriculture Application /03 Agriculture Property /03 Agriculture Property Scheduled / Unscheduled Personal Property /03 Agriculture Liability /09 Agriculture Premises Diagram /09 Agriculture Supplement- Unscheduled Farm Personal Property Inventory Form /03 Livestock Mortality /09 Equine Liability Supplement /03 Small Farm / Ranch Application /06 Surety Report of Execution / / Contract Bond Request Form /06 Commercial or Miscellaneous Bond Request Form /06 Additional Entity Schedule /12 Premium Payment Supplement /07 Claims History / Loss Run Request /01 Railroad Protective Liability Supplement /09 Hotel / Motel Supplement /03 Liquor Liability /03 Directors & Officers Liability /08 P&C Agency Appointment Form /12 Business Income / Extra Expense / Rental Value Supplement to Property /12 Value Reporting Information Supplement to Property /02 Agency Questionnaire /03 Request for Proof of Property /02 International Liability Exposure Supplement /06 International Property Exposure Supplement /10 Producer Information Form (PIF) /07 Driver Work / School Address Information Supplement /12 Additional Premises Information Schedule /05 Professional / Specialty Application For Use in Management, Executive & Professional Lines Applicant /03 Employment Practices Liability /03 Fiduciary Liability /05 Forms and Endorsements Schedule /11 Property Card /10 Professional / Specialty Notice of Incident / Claim /03 Miscellaneous E&O /12 Lawyers Professional Liability /12 Cyber and Privacy /12 Accountants Professional Liability /10 Background Check Authorization /10 Disclosure of Intent to Obtain Consumer Report or Investigative Consumer Report (except California) ACORD Member Services Phone: (845) (rev 5/31/2018) All forms are available for download on the ACORD web site ( Page 2 of 13

3 Alabama 50 AL 2007/10 Alabama Identification Card 62 AL 5/98 Alabama Application Supplement 90 AL 2015/12 Alabama Personal Auto Application 137 AL 2015/12 Alabama Commercial Auto 138 AL 2015/12 Alabama Garage and Dealers 290 AL 2014/12 Alabama Personal Automobile Application Alaska 61 AK 7/97 Alaska Auto Supplement UM/UIM Selection 62 AK 2/98 Alaska Auto Supplement Exclusion of Named Drivers 90 AK 2015/12 Alaska Personal Auto Application 137 AK 2015/12 Alaska Commercial Auto 138 AK 2015/12 Alaska Garage and Dealers 171 AK 6/98 Alaska Petition for Executive Officer Waiver 290 AK 2014/12 Alaska Personal Auto Application Arkansas 50 AR 2007/10 Arkansas Proof of Card 61 AR 2010/04 Arkansas Auto Supplement UM/UIM 62 AR 2013/09 Arkansas Personal Umbrella Supplement 67 AR 2000/02 Arkansas Property Supplement Declination of Residential Earthquake 90 AR 2015/12 Arkansas Personal Auto Application 137 AR 2015/12 Arkansas Commercial Auto 138 AR 2015/12 Arkansas Garage and Dealers 180 AR 2016/03 Arkansas Technology E&O 290 AR 2014/12 Arkansas Personal Auto Application 807 AR 2016/03 Arkansas Directors & Officer Liability 827 AR 2016/03 Arkansas Employment Practices Liability 828 AR 2016/03 Arkansas Fiduciary Liability 832 AR 2016/03 Arkansas Miscellaneous E&O 833 AR 2014/12 Arkansas Lawyers Professional Liability 834 AR 2014/12 Arkansas Cyber and Privacy 838 AR 2013/12 Arkansas Accountants Professional Liability Arizona 38 AZ 2003/10 Arizona Notice of Information Practices (Privacy) 50 AZ 2012/ /8 Arizona Identification Card 61 AZ 2001/02 Arizona Auto Supplement UM/UIM Selection 90 AZ 2016/08 Arizona Personal Auto Application 137 AZ 2015/12 Arizona Commercial Auto 138 AZ 2015/12 Arizona Garage and Dealers 290 AZ 2016/08 Arizona Personal Automobile Application California 50 CA 2004/07 California Identification Card 51 CA 2004/07 California Evidence of Liability 52 CA 2007/07 California Fleet Auto Identification Card 61 CA 2008/03 California Auto Supplement Mandatory UM Bodily Injury / Property Damage Offer 64 CA 2004/02 California Supplement Agency Language 65 CA 2004/07 California Supplement Race, National Origin, Gender 66 CA 2017/01 California Offer of Earthquake 67 CA 2011/07 California Residential Property Disclosure 68 CA 2001/03 California Scheduled Personal Property Loss Computation Disclosure 69 CA 2013/10 California Supplement 90 CA 2015/12 California Personal Auto Application 137 CA 2015/12 California Commercial Auto 138 CA 2016/02 California Garage and Dealers 177 CA 2015/09 California Auto Body Repair Consumer Bill of Rights STATE P&C FORMS California (continued) 290 CA 2014/12 California Personal Auto Application 854 CA 2017/09 California FAIR Plan Property Application for Dwelling 855 CA 2016/08 California FAIR Plan Property Application for Commercial 856 CA 2016/08 California FAIR Plan Property Application for Businessowners (BOP) 857 CA 2011/02 California Earthquake Authority Application for Earthquake 860 CA 2004/12 California Auto Supplement Driver Self Certification 861 CA 2011/07 California Residential Property Bill of Rights 877 CA 2015/10 California Disclosure of Intent to Obtain an Investigative Consumer Report Colorado 50 CO 2007/03 Colorado Identification Card 61 CO 2018/04 Colorado Auto Supplement Summary of s 64 CO 2009/01 Colorado Auto Supplement Colorado Offer of Medical Payments 65 CO 2013/02 Colorado Personal Property Supplement Summary of Renters Policy 66 CO 2018/02 Colorado Personal Property Supplement Summary of Condominium Policy 67 CO 2013/02 Colorado Personal Property Supplement Summary of Dwelling Fire Policy 68 CO 2013/02 Colorado Personal Property Supplement Summary of Homeowners Policy 69 CO 2014/01 Colorado Personal Property Supplement Homeowner s Replacement-Cost Policy Applicants 90 CO 2015/12 Colorado Personal Automobile Application 137 CO 2015/12 Colorado Commercial Auto 138 CO 2015/12 Colorado Garage and Dealers 171 CO 2006/01 Colorado Rejection of by Corporate Officers 290 CO 2014/12 Colorado Personal Automobile Application Connecticut 50 CT 2009/01 Connecticut Identification Card 61 CT 2017/09 Connecticut Auto Supplement UM 62 CT 2011/07 Connecticut Personal Supplement Summary of Consumer Protections 66 CT 2015/02 Connecticut FAIR Plan Application for Property / Liability 90 CT 2015/12 Connecticut Personal Auto Application 137 CT 2015/12 Connecticut Commercial Auto 138 CT 2015/12 Connecticut Garage and Dealers 171 CT 2006/08 Connecticut Workers Comp. Comm. Election by Employee who is an Officer of a Corporation, Manager of an LLC, or Member of a Multiple-Member LLC 172 CT 2006/08 Connecticut Workers Com. Comm. Election by Employees who are Members of a Partnership 173 CT 2006/08 Connecticut Workers Com. Comm. Election by Sole Proprietor or Single-Member LLC 290 CT 2014/12 Connecticut Personal Automobile Application ACORD Member Services Phone: (845) (rev.5/31/2018) All forms are available for download on the ACORD web site ( Page 3 of 13

4 Delaware 38 DE 2008/04 Delaware Personal Supplement Notice of Information Practices (Privacy) 61 DE 2018/06 DE Auto Supplement, DE Motorist s Protection Act Required Statement to Policyholders 62 DE 2004/10 DE Auto Supplement, PIP Deductible Options 64 DE 2015/05 Placement Facility of Delaware Basic Property Application 65 PA / DE 2015/05 FAIR Plan Supplementary Questionnaire / WV 67 DE 2012/01 Delaware Supplement 90 DE 2015/12 Delaware Personal Auto Application 137 DE 2015/12 Delaware Commercial Auto 138 DE 2015/12 Delaware Garage and Dealers 171 DE 2006/01 Delaware Executive Officer(s) Exclusion 290 DE 2015/12 Delaware Personal Auto Application District of Columbia 62 DC 2013/09 District of Columbia Personal Property Supplement, Statement Regarding Flood 64 DC 2017/02 Application to District of Columbia Property Facility for Basic Property 66 DC 2017/02 District of Columbia Property Ins. Facility Essential Homeowners Ins. Inspection and Placement p DC 2017/02 District of Columbia Property Ins. Facility Essential Homeowners Ins. Inspection and Placement Application p DC 2013/09 District of Columbia Personal Property Supplement, Statement Regarding Sewer-line Backup 90 DC 2015/12 District of Columbia Personal Auto Application 137 DC 2015/12 District of Columbia Commercial Auto 138 DC 2015/12 District of Columbia Garage and Dealers 290 DC 2014/12 District of Columbia Personal Auto Application Florida 50 FL 2017/12 Florida Auto ID Card 61 FL 2011/10 Florida Auto Supplement Rejection/Election of UM 62 FL 2013/12 Florida Auto Supplement Personal Injury Protection Options 64 FL 2011/10 Florida Auto Supplement Notice to Policyholders Florida Notification of Availability of Uninsured Motorist 65 FL 2007/08 Florida Residential Property Supplement 66 FL 2013/12 Florida Supplement Credit Report Disclosure Information 67 FL 7/94 Florida Homeowners Supplement 70 FL 2012/02 Florida Property Supplement Uniform Mitigation Verification Inspection Form 83 FL 2014/12 Florida Personal Umbrella Application 90 FL 2015/12 Florida Personal Auto Application 125 FL 2016/03 Florida Commercial Application Applicant Information 130 FL 2015/02 Florida Workers Compensation Application 133 FL 2013/03 Florida Workers Comp. Addendum to ACORD 130 FL 137 FL 2015/12 Florida Commercial Auto 138 FL 2012/12 Florida Garage and Dealers 171 FL 2014/10 Florida Notice of Election of 172 FL 2007/08 Florida Revocation of Election to be Exempt 174 FL 2007/08 Florida Revocation of Election of 175 FL 3/97 Florida Workers Compensation Monthly Change Sheet 220 FL 2012/12 Citizens Property Corporation Commercial Residential Wind Only Florida (continued) 221 FL 2002/07 Citizens Property Ins. Corp. Wind Only Supplemental Application Schedule Commercial and Commercial Residential 283 FL 2014/12 Florida Personal Umbrella Application 860 FL 2011/11 Florida Commercial Auto Addendum 862 FL 2013/12 Florida Personal Auto Supplement 863 FL 2013/12 Florida Personal Auto Supplement Georgia 50 GA 2008/11 Georgia 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 Selection 90 GA 2015/12 Georgia Personal Auto Application 137 GA 2015/12 Georgia Commercial Auto 138 GA 2015/12 Georgia Garage and Dealers Georgia State Board of Workers Compensation /05 Notice of Election or Rejection of Workers GA Compensation 290 GA 2014/12 Georgia Personal Automobile Application ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 4 of 13

5 Hawaii 50 HI 2008/01 Hawaii Auto ID Card 60 HI 2010/07 Hawaii Auto Supplement UM/UIM/PIP 90 HI 2015/12 Hawaii Personal Auto Application 94 HI 2001/03 Hawaii Vehicle Inspection Report Supplement 137 HI 2015/12 Hawaii Commercial Auto 138 HI 2015/12 Hawaii Garage and Dealers 290 HI 2015/12 Hawaii Personal Auto Application Idaho 50 ID 2007/10 State of Idaho Liability Identification Card 61 ID 2009/01 Idaho Auto Supplement Idaho Uninsured Motorist and Underinsured Motorist Disclosure Statement 90 ID 2015/12 Idaho Personal Auto Application 137 ID 2015/12 Idaho Commercial Auto 138 ID 2015/12 Idaho Garage and Dealers 290 ID 2014/12 Idaho Personal Automobile Application Illinois 50 IL 2007/03 Illinois Identification Card 61 IL 2015/01 Illinois Auto Supplement UM/UIM 62 IL 2007/08 Illinois Property Supplement Notice of Availability of Earthquake /01 Illinois / Indiana/ Kentucky/ West Virginia Mine Subsidence Property Supplement 67 IL 2012/01 Illinois Supplement Civil Union Disclosure 90 IL 2015/12 Illinois Personal Auto Application 137 IL 2015/12 Illinois Commercial Auto 138 IL 2015/12 Illinois Garage and Dealers 171 IL 2005/06 Illinois FAIR Plan Application for Commercial Property 290 IL 2014/12 Illinois Personal Auto Application Indiana 50 IN 2007/11 Indiana Identification Card /01 Illinois / Indiana/ Kentucky/ West Virginia Mine Subsidence Property Supplement 90 IN 2015/12 Indiana Personal Auto Application 137 IN 2015/12 Indiana Commercial Auto 138 IN 2015/12 Indiana Garage and Dealers 290 IN 2014/12 Indiana Personal Auto Application Iowa 50 IA 2007/08 Iowa Financial Responsibility Card 61 IA 2002/02 Iowa Auto Supplement UM/UIM Offer/Rejection 62 IA 2/98 Iowa Auto Supplement Notice regarding UM/UIM 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 Supplement Disclosure Use of Claims History 67 IA 2010/07 Iowa Personal Supplement Extraordinary Life Circumstances Disclosure 90 IA 2015/12 Iowa Personal Auto Application 137 IA 2015/12 Iowa Commercial Auto 138 IA 2015/12 Iowa Garage and Dealers 290 IA 2014/12 Iowa Personal Automobile Application Kansas 38 KS 2013/12 Kansas Personal Supplement Notice of Information Practices 90 KS 2016/04 Kansas Personal Auto Application 137 KS 2016/04 Kansas Commercial Auto 138 KS 2016/04 Kansas Garage and Dealers 171 KS 2005/11 Kansas Election Of Individual, Partner or Self- Employed Individual 172 KS 2005/11 Kansas Cancel. Of Election Of Individual, Partner or Self-Employed Individual 173 KS 2005/11 Kansas Cancel. of Election Not to Accept 174 KS 2005/11 Kansas Election Not to Accept 176 KS 2005/11 Kansas Election of Employer to Cover Employees 177 KS 2005/11 Kansas Election of for Volunteer Workers 178 KS 2005/11 Kansas Cancel. Of Election of Employer to Cover Employees 179 KS 2005/11 Kansas Cancel. Of Election of for Volunteer Workers 180 KS 2005/11 Kansas Election of for Persons Performing Public Service 181 KS 2005/11 Kansas Cancel. Of Election of for Persons Performing Public Service 182 KS 2001/05 Kansas Election of a Noncompensated Volunteer to be Covered 183 KS 2001/05 Kansas Cancel. of Election of a Noncompensated Volunteer to be Covered 290 KS 2016/04 Kansas Personal Auto Application Kentucky 50 KY 2006/01 Commonwealth of Kentucky Proof of 60 KY 2017/09 Kentucky Auto Supplement Rejection of Uninsured / Underinsured Motorist 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 /01 Illinois / Indiana/ Kentucky/ West Virginia Mine Subsidence Property Supplement 68 KY 2011/01 Kentucky FAIR Plan Commercial Fire Application 90 KY 2015/09 Kentucky Personal Auto Application 137 Kentucky Commercial Auto 2015/09 KY 138 Kentucky Garage and Dealers 2015/09 KY 290 Kentucky Personal Auto Application 2015/09 KY ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 5 of 13

6 Louisiana 50 LA 2008/ /10 Louisiana Auto Identification Card 60 LA 4/98 Louisiana Dwelling Supplement Loss Settlement DWG1 61 LA 2001/05 Louisiana Homeowners Supplement Loss Settlement (HO4) 62 LA 4/98 Louisiana Commercial Property Supplement 64 LA 2001/05 Louisiana Homeowners Supplement Loss Settlement (HO2 & 3) 65 LA 2001/02 Louisiana Homeowners Supplement Loss Settlement (HO6) 66 LA 4/98 Louisiana Dwelling Supplement Loss Settlement DWG2 & 3 67 LA 5/98 Louisiana Certification of Mobile Home Tie Downs 68 LA 4/98 Louisiana Plan Services Application for 90 LA 2015/12 Louisiana Personal Auto Application 137 LA 2015/12 Louisiana Commercial Auto 138 LA 2015/12 Louisiana Garage and Dealers 290 LA 2014/12 Louisiana Personal Auto Application 861 LA 2005/07 Louisiana Auto Supplement Active Military Personnel Affidavit 862 LA 2009/06 Louisiana Property Supplement Hurricane Loss Mitigation Survey Maine 50 ME 2007/08 Maine Motor Vehicle Identification Card 90 ME 2015/12 Maine Personal Auto Application 137 ME 2015/12 Maine Commercial Auto 138 ME 2015/12 Maine Garage and Dealers 290 ME 2015/12 Maine Personal Auto Application Selection Maryland 39 MD 2016/05 Maryland Personal Supplement 50 MD 2016/10 Maryland Motor Vehicle Liability Identification Card 62 MD 1/98 Maryland Commercial Auto Supplement 64 MD 2017/02 Maryland Property Availability Program Essential Property Inspection and Placement 65 MD 2017/02 Maryland Property Availability Program Essential Homeowners Inspection an Placement (p. 1 of 2) 66 MD 2017/02 Maryland Property Availability Program Essential Homeowners Inspection an Placement (p. 2 of 2) 67 MD 2011/ /7 Maryland Personal Auto Supplement Mandatory Offer of Increased Liability for Claims of Family Members, Mandatory PIP Waiver, and Mandatory UM Waiver 68 MD 2007/01 Maryland Personal Property Supplement Statement Regarding Flood 69 MD 2013/10 Maryland Supplement Notice of Underwriting Period 90 MD 2015/ /7 Maryland Personal Auto Application 95 MD 2018/07 Maryland Required Notice of UM and Enhanced Motorist ( EUIM ) and Option Selection Form 137 MD 2015/12 Maryland Commercial Auto 138 MD 2015/12 Maryland Garage and Dealers 290 MD 2014/ /7 Maryland Personal Automobile Application 851 MD 2008/11 Maryland Personal Property Supplement Loss from Water and Sewer Backup 852 MD 2012/10 Maryland Personal Property Supplement Homeowner s, Limitation of Claims Made Notice 853 MD 2014/01 Maryland Personal Property Supplement Massachusetts 60 MA 2017/11 Massachusetts Property Underwriting Association Application for Homeowners 61 MA 2017/11 Massachusetts Property Underwriting Association Instructions to Complete Homeowners Application ACORD 60 MA 64 MA 2/97 Massachusetts Residential Property Liability Supplement Lead Poisoning Liability Disclosure Notice 65 MA 2017/11 Massachusetts Property Underwriting Association Application for Dwelling Fire and Liability Inspection and Placement 66 MA 2015/01 Massachusetts Property Ins. Underwriting Assn. Instructions for Completing Dwelling Fire and Liability Inspection and Placement 67 MA 2003/04 Massachusetts Property Ins. Underwriting Assn. Application for Commercial Fire Inspection and Placement 68 MA 2003/04 Massachusetts Property Ins. Underwriting Assn. Inspection Notice, Credit Reporting notice and Instructions for Completing Commercial Fire Application ACORD 67 MA 69 MA 2010/07 Massachusetts Residential Property Liquid Fuel Spill Supplement 90 MA 2016/09 Application for Massachusetts Motor Vehicle 95 MA 2009/12 Massachusetts Renewal Application (Statement of Facts) 137 MA 2015/12 Massachusetts Commercial Auto 138 MA 2015/12 Massachusetts Garage and Dealers Michigan 50 MI 2010/08 State of Michigan Certificate of No-Fault 60 MI 2010/03 Michigan Automobile Placement Facility Michigan Auto Supplement Declaration of Intent to Reside 62 MI 2014/03 Michigan Collision Options Notice 64 MI 2000/10 Michigan Basic Property Assn. Application 90 MI 2015/12 Michigan Personal Auto Application 133 MI 2012/08 Michigan Application for Workers Compensation 137 MI 2015/12 Michigan Commercial Auto 138 MI 2015/12 Michigan Garage and Dealers 139 MI 2004/07 Michigan Automobile Placement Facility Supplement to ACORD App. Application for Commercial, Public Automobiles and Corporately Owned Vehicles 171 MI 2005/01 Michigan Notice of Election 172 MI 4/96 Michigan Application for Exclusion of Partner(s), Spouse, Child or Parent 173 MI 2000/09 Michigan WC Placement Facility Specific Person Exclusion 290 MI 2014/12 Michigan Personal Automobile Application 860 MI 2010/03 Michigan Auto Supplement Declaration of Intent to Reside ACORD Member Services Phone: (845) (rev 5/31/2018 ) All forms are available for download on the ACORD web site ( Page 6 of 13

7 Minnesota 38 MN 2013/01 Minnesota Authorization 62 MN 2000/01 Minnesota Auto Supplement 65 MN 2012/04 Minnesota Guarantee Association Notice 90 MN 2015/12 Minnesota Personal Auto Application 137 MN 2015/12 Minnesota Commercial Auto 138 MN 2015/12 Minnesota Garage and Dealers 290 MN 2015/12 Minnesota Personal Auto Application 807 MN 2016/03 Minnesota Directors & Officers Liability 827 MN 2016/03 Minnesota Employment Practices Liability 828 MN 2016/03 Minnesota Fiduciary Liability 832 MN 2016/03 Minnesota Miscellaneous E&O 833 MN 2014/12 Minnesota Lawyers Professional Liability 834 MN 2014/12 Minnesota Cyber and Privacy 838 MN 2013/12 Minnesota Accountants Professional Liability 853 MN 2010/08 Minnesota Homeowners Personal Property Supplement Mississippi 50 MS 2008/01 Mississippi Auto ID Card 61 MS 2013/07 Mississippi Auto Supplement Non-Stacking UM 62 MS 2016/07 Mississippi Auto Supplement Selection / Rejection of Uninsured Motorist 66 MS 2016/11 Mississippi Supplement 90 MS 2016/07 Mississippi Personal Auto Application 137 MS 2016/07 Mississippi Commercial Auto 138 MS 2016/07 Mississippi Garage and Dealers 139 MS 2/99 Mississippi Statements/Schedule of Values 290 MS 2016/07 Mississippi personal Auto Application Missouri 50 MO 2007/05 Missouri Auto ID Card 62 MO 2007/08 Missouri Property Supplement Notice of Availability Earthquake 67 MO 2009/06 Missouri FAIR Plan Application 90 MO 2015/12 Missouri Personal Auto Application 137 MO 2015/12 Missouri Commercial Auto 138 MO 2015/12 Missouri Garage and Dealers 290 MO 2014/12 Missouri Personal Auto Application Montana 60 MT 2003/09 Montana Application Supplement Refusal to Renew 90 MT 2015/12 Montana Personal Auto Application 137 MT 2015/12 Montana Commercial Auto 138 MT 2015/12 Montana Garage and Dealers 290 MT 2015/23 Montana Personal Auto Application 807 MT 2016/03 Montana Directors & Officers Liability 827 MT 2016/03 Montana Employment Practices Liability s 828 MT 2016/03 Montana Fiduciary Liability 832 MT 2016/03 Montana Miscellaneous E&O 833 MT 2014/12 Montana Lawyers Professional Liability 834 MT 2014/12 Montana Cyber and Privacy 838 MT 2013/12 Montana Accountants Professional Liability Nebraska 50 NE 2007/01 Nebraska Auto Liability Identification Card 90 NE 2015/12 Nebraska Personal Auto Application 137 NE 2015/12 Nebraska Commercial Auto 138 NE 2015/12 Nebraska Garage and Dealers 290 NE 2014/12 Nebraska Personal Auto Application Nevada 51 NV 2016/07 Nevada Temporary Identification Card 52 NV 2016/07 Nevada Permanent Identification Card 53 NV 2016/07 Nevada Temporary Identification Card, Evidence of Operator s Policy of Liability 54 NV 2016/07 Nevada Permanent Identification Card, Evidence of Operator s Policy of Liability 61 NV 2002/12 Nevada Auto Supplement, Mandatory Offer of Medical Payments and Uninsured Motorists 62 NV 2001/05 Nevada Umbrella Supplement 90 NV 2015/12 Nevada Personal Auto Application 137 NV 2015/12 Nevada Commercial Auto 138 NV 2015/12 Nevada Garage and Dealers 290 NV 2014/12 Nevada Personal Auto Application New Hampshire 90 NH 2015/12 New Hampshire Personal Auto Application 137 NH 2018/05 New Hampshire Commercial Auto 138 NH 2015/12 New Hampshire Garage and Dealers 290 NH 2014/12 New Hampshire Personal Auto Application New Jersey 50 NJ 2016/12 State of New Jersey Temporary Evidence of 51 NJ 2016/12 State of New Jersey Identification Card 60 NJ 2001/10 New Jersey Homeowners Supplement Flood Exclusion 61 NJ 2016/09 New Jersey Auto Buyer s Guide 62 NJ 2018/05 New Jersey Auto Supplement Basic Policy 64 NJ 2018/05 New Jersey Auto Supplement Standard Policy 65 NJ 2017/04 New Jersey Property Supplement Earthquake 66 NJ 2016/09 New Jersey Auto Buyer s Guide Commercial PPA Edition 67 NJ 2018/06 NJUIA Dwelling Fire Application 68 NJ 2018/06 NJUIA Commercial Fire Application 90 NJ 2015/12 New Jersey Personal Auto Application 94 NJ 2006/04 Inspection Report 132 NJ 2015/09 New Jersey Workers Compensation Plan Notes and Instructions ( Request Form) 133 NJ 2015/09 New Jersey Workers Compensation Plan Request Form 134 NJ 2015/09 New Jersey Workers Compensation Plan Notice of Election Proprietors and Partners 135 NJ 2015/09 New Jersey Workers Compensation Plan Employee Leasing Supplemental Request Form 136 NJ 2015/09 New Jersey Workers Compensation Plan Truckers Supplemental Request Form 137 NJ 2015/12 New Jersey Commercial Auto 138 NJ 2015/12 New Jersey Garage and Dealers 171 NJ 2003/07 New Jersey Workers Compensation Plan NJ Workers compensation and Employers Liability Manual Part 3, NJ 2015/12 New Jersey Personal Auto Application ACORD Member Services Phone: (845) (rev.5/31/2018) All forms are available for download on the ACORD web site ( Page 7 of 13

8 New Mexico 60 NM 2003/01 New Mexico Confidential Abuse Disclosure 61 NM 2010/12 New Mexico Auto Supplement UM Selection / Rejection and Rejection of Stacked UM 90 NM 2015/12 New Mexico Personal Auto Application 137 NM 2015/12 New Mexico Commercial Auto 138 NM 2015/12 New Mexico Garage and Dealers 171 NM 2004/10 New Mexico Executive Employee Affirmative Election Form 172 NM 2004/10 New Mexico Election to Accept 173 NM 2004/10 New Mexico Revocation 174 NM 2004/10 New Mexico Limited Liability Company Member Affirmative Election Form 290 NM 2014/12 New Mexico Personal Auto Application New York 38 NY 2005/04 New York Personal Supplement Notice of Information Practices 39 NY 2011/03 New York Supplement 60 NY 2008/03 New York Homeowners Supplement 61 NY 3/94 New York Auto Supplement (Optional Basic Econ. Loss) 62 NY 2009/04 New York Application for Dwelling NYPIUA 64 NY 2018/06 New York Auto Supplement Supp. UM/UIM 65 NY 2003/01 New York Auto Supplement Spousal Liability 66 NY 2012/01 New York Auto Supplement Rental Reimbursement Notice 67 NY 2009/04 Instructions for Completion of ACORD 62 NY 68 NY 2002/01 New York Liability Supplement Claims-Made Policy 69 NY 2008/08 New York Personal Property Supplement Important Flood Notice 70 NY 2006/04 NYPIUA Instructions for Completing ACORD 177 NY 90 NY 2015/12 New York Personal Auto Application 137 NY 2015/12 New York Commercial Auto 138 NY 2015/12 New York Garage and Dealers 171 NY 10/96 New York Notice of Election of a Corporation 172 NY 7/96 New York Election of Partners or Self-Employed Persons for Workers Compensation 173 NY 7/96 New York Election of Executive Officers of an Organization for Workers Compensation 174 NY 7/96 New York Revocation of Executive officers of an Organization for Workers Compensation 177 NY 2006/04 NYPIUA Application for Commercial 290 NY 2015/12 New York Personal Auto Application 855 NY 2014/05 New York Construction Certificate of Liability Addendum North Carolina 64 NC 2008/04 North Carolina Property Supplement Prop. Ins. Notice Disclosure 65 NC 2010/02 North Carolina Auto Supplement Notice of Right to Purchase Higher Limits of Uninsured Motorist (UM) and Underinsured Motorist (UIM) 66 NC 8/97 North Carolina Supplement Consent to Obtain Credit or Consumer Investigative Report 67 NC 2012/03 North Carolina Supplement Policy Service Fee Schedule 90 NC 2016/05 North Carolina Personal Auto Application 135 NC 2015/10 North Carolina Workers Comp. Plan Application 136 NC 2015/10 NCWCIP, Instructions for Completing ACORD 135 NC App. 137 NC 2015/12 North Carolina Commercial Auto 138 NC 2015/12 North Carolina Garage and Dealers 290 NC 2016/05 North Carolina Personal Automobile Application North Dakota 38 ND 2005/08 North Dakota Personal Supplement Notice of Information Practices 50 ND 2007/08 North Dakota Identification Card 62 ND 2015/04 North Dakota Supplement 68 ND 2004/07 North Dakota Supplement to Property Fire District 90 ND 2015/12 North Dakota Personal Auto Application 137 ND 2015/12 North Dakota Commercial Auto 138 ND 2015/12 North Dakota Garage and Dealers 290 ND 2014/12 North Dakota Personal Auto Application Ohio 62 OH 2011/05 Ohio Auto Supplement Important Optional Disclosure Notice Uninsured Motorist Property Damage 67 OH 2009/07 Ohio Mine Subsidence Homeowners and Dwelling Supplement 68 OH 2009/07 Ohio Offer of Mine Subsidence Homeowner and Dwellings 90 OH 2015/12 Ohio Personal Auto Application 137 OH 2015/12 Ohio Commercial Auto 138 OH 2015/12 Ohio Garage and Dealers 170 OH 2002/09 Ohio FAIR Plan Instructions for Completion of Apps. 171 OH 2004/03 Ohio FAIR Plan Basic Property Application 172 OH 2002/09 Ohio FAIR Plan Homeowners Supplement 173 OH 2002/09 Ohio FAIR Plan Dwelling Fire Supplement 174 OH 2002/09 Ohio FAIR Plan Commercial Supplement 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 2014/12 Ohio Personal Automobile Application 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 Law 62 OK 2006/05 Oklahoma Property Supplement Notice to Property Owners in Rural Fire Protection Districts 64 OK 2007/10 Oklahoma Liability Supplement 90 OK 2015/12 Oklahoma Personal Auto Application 137 OK 2015/12 Oklahoma Commercial Auto 138 OK 2015/12 Oklahoma Garage and Dealers 290 OK 2014/12 Oklahoma Personal Automobile Application Oregon 38 OR 2013/01 Oregon Notice of Information Practices (Privacy) 61 OR 2016/01 Oregon Auto Supplement UM Selection 62 OR 2006/01 Oregon Personal Lines Supplement 90 OR 2016/01 Oregon Personal Auto Application 137 OR 2016/01 Oregon Commercial Auto 138 OR 2016/01 Oregon Garage and Dealers 290 OR 2016/01 Oregon Personal Auto Application ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 8 of 13

9 Pennsylvania 50 PA 2007/09 Pennsylvania Financial Responsibility Card 60 PA 2012/10 Pennsylvania UM Select/Reject 61 PA 2014/02 Pennsylvania Auto Supplement Important Notice 62 PA 2012/10 Pennsylvania UIM Select/Reject 64 PA 2015/05 Placement Facility of Pennsylvania Basic Property Application 65 PA / DE/ 2015/05 FAIR Plan Supplementary Questionnaire WV 66 PA 2015/05 Placement Facility of Pennsylvania Dwelling Property 2 Broad Form Application Supplement 90 PA 2015/12 Pennsylvania Personal Auto Application 137 PA 2015/12 Pennsylvania Commercial Auto 138 PA 2015/12 Pennsylvania Garage and Dealers 171 PA 2002/02 Pennsylvania Application for Executive Officer Exception 172 PA 2002/02 Pennsylvania Executive Officers Declaration 290 PA 2015/12 Pennsylvania Personal Auto Application Puerto Rico 90 PR 2015/12 Puerto Rico Personal Auto Application 290 PR 2014/12 Puerto Rico Personal Auto Application Rhode Island 50 RI 2008/01 Rhode Island Identification Card 61 RI 2012/12 Rhode Island Auto Supplement, Uninsured / Underinsured Motorist Bodily Injury 62 RI 2006/01 Rhode Island Prop. Suppl. Notice of Flood Exclusion 64 RI 2018/01 Rhode Island Joint Reinsurance Association, Application for Homeowners Inspection and Placement 65 RI 2003/04 Rhode Island Joint Reinsurance Association, Instructions for Completing Homeowners Applications ACORD 64 RI 66 RI 2012/07 Rhode Island Joint Underwriting Application for Dwelling Fire and Personal Liability Inspection and Placement 67 RI 2007/03 Rhode Island Joint Underwriting Inspection Notice, Credit Reporting Notice and Instructions for Completing Dwelling Fire and Personal Liability Application ACORD 66 RI 68 RI 2017/12 Rhode Island Joint Underwriting Application for Commercial Fire Inspection and Placement 69 RI 2003/04 Rhode Island Joint Underwriting Inspection Notice, Credit Reporting Notice and Instructions for Completing Commercial Fire Application ACORD 68 RI 90 RI 2015/12 Rhode Island Personal Auto Application 137 RI 2015/12 Rhode Island Commercial Auto 138 RI 2015/12 Rhode Island Garage and Dealers 290 RI 2016/06 Rhode Island Personal Automobile Application South Carolina 50 SC 2007/01 South Carolina Identification Card 61 SC 2007/08 South Carolina Auto Supplement Offer of Opt UM/UIM 64 SC 2008/03 South Carolina Personal Property Supplement Cancellation Rules Disclosure 90 SC 2015/12 South Carolina Personal Auto Application 137 SC 2015/12 South Carolina Commercial Auto 138 SC 2015/12 South Carolina Garage and Dealers 290 SC 2014/12 South Carolina Personal Automobile Application South Dakota 50 SD 2007/02 South Dakota Identification Card 61 SD 2013/02 South Dakota Personal Umbrella Supplement 90 SD 2015/12 South Dakota Personal Auto Application 137 SD 2015/12 South Dakota Commercial Auto 138 SD 2015/12 South Dakota Garage and Dealers 180 SD 2016/03 South Dakota Technology E&O 290 SD 2014/12 South Dakota Personal Auto Application Tennessee 50 TN 2007/02 Tennessee Identification Card 90 TN 2015/12 Tennessee Personal Auto Application 137 TN 2015/12 Tennessee Commercial Auto 138 TN 2015/12 Tennessee Garage and Dealers 290 TN 2014/12 Tennessee Personal Automobile Application Texas 50 TX 2015/ /9 Texas Liability Card 60 TX 2016/03 Texas Consumer Bill of Rights for Personal Auto 62 TX 2016/03 Texas Consumer Bill of Rights for Personal Auto (Spanish) 64 TX 2003/04 Texas Windstorm Association Application 67 TX 2016/03 Texas Homeowners and Personal Property Rights 68 TX 2016/03 Texas Homeowners and Personal Property Rights (Spanish) 69 TX 2000/08 Texas Special Mobile Home Windstorm/Hail Application 90 TX 2015/12 Texas Personal Auto Application 137 TX 2015/12 Texas Commercial Auto 138 TX 2015/12 Texas Garage and Dealers 290 TX 2015/12 Texas Personal Automobile Application 851 TX 2010/06 TX Personal Lines Supp. Use of Credit Information Disclosure 852 TX 2010/06 TX Personal Lines Supp. (Spanish Version) Use of Credit Information Disclosure 853 TX 2014/01 Texas Personal Auto Supplement 854 TX 2012/08 Texas Risk Pool Certificate of Property 855 TX 2015/02 Texas Risk Pool Certificate of Liability ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 9 of 13

10 United States 60 US 2015/01 Supplement Offer of Terrorism 62 US 2015/01 Supplement Offer of Terrorism Standard Fire Policy 64 US 2015/01 Supplement Offer of Terrorism Workers Compensation Utah 51 UT 2014/07 Utah Identification Card 61 UT 2013/04 Utah Auto Supplement Uninsured / Underinsured Motorist Selection 63 UT 9/93 Utah Fraud Statement 66 UT 6/94 Utah Arbitration Provisions 67 UT 10/94 Utah Auto Supplement PIP, Loss of Income Waiver 90 UT 2015/12 Utah Personal Auto Application 137 UT 2015/12 Utah Commercial Auto 138 UT 2015/12 Utah Garage and Dealers 290 UT 2014/12 Utah Personal Auto Application Vermont 50 VT 2007/02 Vermont Automobile Identification Card 66 VT 2003/06 Vermont Supplement Fair Credit Reporting Act 90 VT 2015/12 Vermont Personal Auto Application 137 VT 2015/12 Vermont Commercial Auto 138 VT 2015/12 Vermont Garage and Dealers 290 VT 2014/12 Vermont Personal Auto Application Virgin Islands 90 VI 2015/12 Virgin Islands Personal Auto Application 137 VI 2014/08 Virgin Islands Commercial Auto 138 VI 2015/06 Virgin Islands Garage and Dealers 290 VI 2014/12 Virgin Islands Personal Auto Application Virginia 38 VA 2011/05 Virginia Notice of Information Practices (Privacy) 60 VA 8/94 Virginia Auto Supplement Rental Reimbursement 62 VA 6/97 Virginia Property Supplement Ordinance or Law ; Additional Cov. Available 64 VA 2005/01 Virginia Property Supplement Notice of Flood 67 VA 2000/11 Virginia Property Association 90 VA 2015/12 Virginia Personal Auto Application 137 VA 2015/12 Virginia Commercial Auto 138 VA 2015/12 Virginia Garage and Dealers 290 VA 2014/12 Virginia Personal Auto Application Washington 90 WA 2016/12 Washington Personal Auto Application 137 Washington Commercial Auto 2016/12 WA 138 Washington Garage and Dealers 2016/12 WA 290 Washington Personal Auto Application 2016/12 WA West Virginia 38 WV 2006/04 West Virginia Personal Supplement Notice of Information Practices 50 WV 2014/01 West Virginia Certificate of 60 WV 2016/01 West Virginia Auto Supplement UM / UIM Vehicle 61 WV 2016/01 West Virginia Auto Supplement UM / UIM Offer Split Limits 62 WV 2016/01 West Virginia Auto Supplement UM / UIM Offer Single Limits 64 WV 2015/05 West Virginia Essential Property Association Basic Property Application 65 WV 2016/01 West Virginia Umbrella Liability Supplement Important Notice 65 PA / DE / 2015/05 FAIR Plan Supplementary Questionnaire WV 66 WV 2016/01 West Virginia Personal and Commercial Umbrella Liability Supplement UM / UIM Offer of Split Limits /01 Illinois / Indiana/ Kentucky/ West Virginia Mine Subsidence Property Supplement 68 WV 2016/01 West Virginia Umbrella Liability Supplement UM / UIM Offer of Single Limits 90 WV 2015/12 West Virginia Personal Auto Application 137 WV 2015/12 West Virginia Commercial Auto 138 WV 2015/12 West Virginia Garage and Dealers 290 WV 2014/12 West Virginia Personal Auto Application 862 West Virginia Property Supplement Notice of 2005/07 WV Flood Exclusion Wisconsin 4 WI 2003/04 Wisconsin Employers First Report of Injury or Disease 90 WI 2015/12 Wisconsin Personal Auto Application 97 WI 2003/10 Wisconsin Automobile Plan Private Passenger Auto Application 133 WI 2010/04 Wisconsin Workers Compensation Pool 134 WI 8/99 Wisconsin Supplementary Non-Election Form 135 WI 8/99 Wisconsin Supplementary Election of Form 136 WI 2010/04 Wisconsin Supplement Limited Other States Request 137 WI 2015/12 Wisconsin Commercial Auto 138 WI 2015/12 Wisconsin Garage and Dealers 177 WI 2011/11 Wisconsin Automobile Plan Business Auto Application 178 WI 2011/11 Wisconsin Automobile Plan Truckers Application 290 WI 2016/06 Wisconsin Personal Auto Application Wyoming 90 WY 2015/12 Wyoming Personal Auto Application 137 WY 2015/12 Wyoming Commercial Auto 138 WY 2015/12 Wyoming Garage and Dealers 290 WY 2014/12 Wyoming Personal Auto Application ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 10 of 13

11 Number Edition Title /02 Home Certificate of Currency /02 Private Motor Certificate of Currency /02 Professional Indemnity Certificate of Currency /02 Commercial Motor Certificate of Currency /02 Interested Party Schedule /03 Home Application for /03 Personal Motor Application for /03 Personal Motor Vehicle Schedule /02 Additional Remarks Schedule /02 Commercial Motor Vehicle Schedule /02 Commercial Motor Application for /02 Commercial Driver Schedule /02 Additional Situations Schedule /02 Professional Indemnity Application /02 Industrial Special Risks Application /10 Business Package Application for ACORD Australia Forms Available ONLY on the ACORD Web Site AUSTRALIA FORMS Number Edition Title ACORD Member Services Phone: (845) (rev 5/31/2018) All forms are available for download on the ACORD web site ( Page 11 of 13

12 ACORD Life/Annuity/Health Forms Available ONLY on the ACORD Web Site Number Edition Title /01 Authorization for the Release of Health Information /07 Electronic Funds Transfer Authorization Form for Long Term Care /07 Credit Card Payment Authorization Form for Long Term Care /04 Policy Delivery Receipt /05 Request for Proposal Additional Unions Schedule /05 Request for Proposal Additional Locations Schedule /05 Request for Proposal Additional Covered Affiliates Schedule /01 Illustration Certification and Acknowledgement /12 Important Notice Regarding Replacement Model Regulation States /03 Important Notice Regarding Replacement /03 Fair Credit Reporting Act Disclosure /01 Agent s Report /03 Life Product Comparison Form /10 Laboratory Identification Form /01 Informal Inquiry Application Part 2 Medical History /01 Medical Examiner s Report /01 HIV Antibody/Antigen Consent and Testing Form /01 Informal Inquiry Application Part 2 Medical History Medical Conditions Details / Additional Care Providers /07 Request for Proposal Employee Benefits /07 Request for Proposal Life Supplement /07 Request for Proposal Short Term Disability Supplement /07 Request for Proposal Long Term Disability Supplement /05 Age Banded Rate Supplement /05 Reducing Benefit Duration Schedule /05 Administrative Services and Fee Schedule Long Term Disability /05 Administrative Services and Fee Schedule Short Term Disability COUNTRYWIDE LIFE FORMS Number Edition Title /01 Request for Proposal Dental and Vision Supplement /10 Producer Information Form (PIF) /10 Background Check Authorization /10 Disclosure of Intent to Obtain Consumer Report or Investigate Consumer Report (except California) / Exchange / Rollover/ Transfer Form 951e 2017/ Exchange / Rollover / Transfer eform ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 12 of 13

13 ACORD Life/Annuity/Health Forms Available ONLY on the ACORD Web Site 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 760 CA 2015/06 California Notice Regarding Replacement 877 CA 2015/10 California Disclosure of Intent to Obtain an Investigative Consumer Report 966 CA 2007/03 California Annuity Product Comparison Form District of Columbia 757 DC 2004/07 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 761 FL 2016/07 Florida Surrender of an Annuity or Life Policy 966 FL 2007/03 Florida Annuity Product Comparison Form 969 FL 2007/03 Florida Annuity Product Comparison Form Supplement Policy / Rider Description Delaware 760 DE 2017/01 Delaware Notice Regarding Replacement Georgia 760 GA 2017/01 Georgia Notice Regarding Replacement Idaho 760 ID 2017/01 Idaho Notice Regarding Replacement Illinois 760 IL 2017/06 Illinois Notice Regarding Replacement Indiana 760 A IN 2018/01 Indiana Notice Regarding Replacement 760 B IN 2018/01 Indiana Notice Regarding Replacement With Direct Response Sale Massachusetts 757 MA 2004/11 Massachusetts HIV Antibody/Antigen Consent and Testing Form 760 MA 2015/06 Massachusetts Important Notice Regarding Replacement STATE LIFE FORMS Number Edition Title Michigan 757 MI 2004/12 Michigan HIV Antibody/Antigen Consent and Testing Form Minnesota 760 MN 2015/12 Minnesota Notice Regarding Replacement New York 751 NY 2005/11 New York Authorization to Obtain and Disclose Information 753 NY 2005/11 New York Notice of Information Practices (Pre Notice) 757 NY 2005/11 New York HIV Antibody/Antigen Consent and Testing Form 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 Virginia 655 VA 2010/12 Virginia Group Health 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 ACORD Member Services Phone: (845) (rev. 5/31/2018) All forms are available for download on the ACORD web site ( Page 13 of 13