ACORD Forms in ebixasp (03/2004)
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1 ACORD Forms in ebixasp (03/2004) Form number Form Name Edition Date 1 Property Loss Notice 2002/1 2 Automobile Loss Notice 2002/1 3 General Liability Notice of Occurrence/Claim 2002/1 4 Workers Compensation - First Report of Injury of Illness 2001/2 24 Certificate of Property Insurance 1995/1 25 Certificate of Insurance 2001/8 27 Evidence of Personal Property (R-9/03) 2003/3 28 Evidence of Commercial Property (New) 2003/10 35 Cancellation Request/Policy Release 1997/1 36 Agent/Broker of Record Change (New) (Pending) 1/98 38 MO Missouri Notice of Information Practices (Pending) 2002/09 38 NH New Hampshire Notice of Information Practices (Pending) 2002/09 39 MD Maryland Application Supplement (Pending) 2003/05 40 RESIDENTIAL PROPERTY VALUATION SURVEY 2000/ RESIDENTIAL PROPERTY REPLACEMENT COST WORKSHEET - Boeckh Square Foot Method RESIDENTIAL PROPERTY REPLACEMENT COST - Information Supplement 1998/1 2001/5 45 Additional Interest 1993/3 50 AR Arkansas Proof of Insurance Card (Pending) 2003/07 50 GA Georgia Insurance Policy Information Card (New) 2004/01 50 IA Iowa Financial Liability Coverage Card (Pending) 2002/12 50 OK Oklahoma Owners Security Verification Form (Pending) 2002/07 50 PA Pennsylvania Proof of Insurance Card (Pending) 2002/08 51 OK Oklahoma Operators Security Verification Form (Pending) 2002/07 60 Insurance Supplement -Notice- Offer of Terrorism Coverage 2003/1 60 MT Montana Application Supplement-Refusal to Renew (Pending) 2003/09 60 Flood Insurance Notice/Rejection (New) Pending 2002/09 61 AZ Arizona Auto Supplement 2002/09 61 FL Florida Auto Supplement 2001/11 61 GA Georgia Auto Supplement (Pending) 1999/1 61 MS Mississippi Auto Supplement (Pending) 2002/09 62 Insurance Supplement-Standard Fire Policy Only -Notice- Offer of Terrorism Coverage 2003/1 62 AZ Arizona Auto Supplement Spanish Version (Pending) 2003/05 64 US Insurance Supplement-Workers Compensation Only (Pending) 2003/02 65 MA Massachusetts Property Insurance Underwriting Assoc. (Pending) 2003/04 65 NJ New Jersey Property Insurance Supplement 2003/02 65 NY New York Auto Supplement 2003/1 67 FL Florida Homeowners Supplement 1994/7 70 Personal Policy Change Request (Except Auto) (R-8/03) 2001/5 71 Personal Auto Change Request ACORD (R-9/03) 2001/5 71 SC South Carolina Personal Auto Change Request ACORD 2001/4 73 SOLID FUEL QUESTIONNAIRE - Personal Property Supplement 2000/8 75 Insurance Binder 2001/1 80 HOMEOWNER APPLICATION (R9/03) 2002/1
2 81 Personal Inland Marine Application 2001/4 82 Watercraft Application 2001/2 83 Personal Umbrella Application (R9/03) 2001/3 84 DWELLING FIRE APPLICATION (R9/03) 2002/1 85 Mobile Home Owners (R9/03) 2001/4 86 Personal Lines Package Application (R9/03) 2001/4 87 Personal Lines Package Application - Watercraft/Inland Marine Supplement 2000/12 90 AL Alabama Personal Auto Application 2001/2 90 AK Alaska Personal Auto Application 2001/2 90 AZ Arizona Personal Auto Application 2001/3 90 AR Arkansas Personal Auto Application 2000/10 90 AE Armed Forces Europe Personal Auto Application 1900/1 90 AP Armed Forces Pacific Personal Auto Application 1900/1 90 CA California Personal Auto Application 2000/1 90 CO Colorado Personal Auto Application 1999/1 90 CT Connecticut Personal Auto Application 2003/6 90 DE Delaware Personal Auto Application 1998/8 90 DC District Of Columbia Personal Auto Application 2001/5 90 FL Florida Personal Auto Application (10/03) 2002/1 90 GA Georgia Personal Auto Application 2001/2 90 HI Hawaii Personal Auto Application 2001/2 90 ID Idaho Personal Auto Application 2001/3 90 IL Illinois Personal Auto Application 2002/1 90 IN Indiana Personal Auto Application 2000/8 90 IA Iowa Personal Auto Application 2001/3 90 KS Kansas Personal Auto Application 2000/9 90 KY Kentucky Personal Auto Application 2000/9 90 LA Louisiana Personal Auto Application 1998/6 90 ME Maine Personal Auto Application 2000/9 90 MD Maryland Personal Auto Application 1998/1 90 MA Massachusetts Personal Auto Application 2000/1 90 MI Michigan Personal Auto Application 1996/10 90 MN Minnesota Personal Auto Application 2000/1 90 MS Mississippi Personal Auto Application 2001/3 90 MO Missouri Personal Auto Application 2002/9 90 MT Montana Personal Auto Application 2001/3 90 NE Nebraska Personal Auto Application 2000/8 90 NV Nevada Personal Auto Application 2001/3 90 NH New Hampshire Personal Auto Application 2001/3 90 NJ New Jersey Personal Auto Application 2000/9 90 NM New Mexico Personal Auto Application 2001/3 90 NY New York Personal Auto Application 2003/3 90 NC North Carolina Personal Auto Application 2000/9 90 ND North Dakota Personal Auto Application 2000/10 90 OH Ohio Personal Auto Application 2001/3 90 OK Oklahoma Personal Auto Application 2001/3 90 ON Ontario Personal Auto Application 1900/1 90 OR Oregon Personal Auto Application 1998/2 90 PA Pennsylvania Personal Auto Application 2000/9 90 PR Puerto Rico Personal Auto Application 2001/3
3 90 RI Rhode Island Personal Auto Application 2001/3 90 SC South Carolina Personal Auto Application 2001/4 90 SD South Dakota Personal Auto Application 1998/9 90 TN Tennessee Personal Auto Application 1998/11 90 TX Texas Personal Auto Application 2001/3 90 UT Utah Personal Auto Application 2001/1 90 VT Vermont Personal Auto Application 2001/1 90 VI Virgin Islands Personal Auto Application 2001/3 90 VA Virginia Personal Auto Application 1998/10 90 WA Washington Personal Auto Application 2000/8 90 WV West Virginia Personal Auto Application 2001/3 90 WI Wisconsin Personal Auto Application 2001/3 90 WY Wyoming Personal Auto Application 2001/3 125 Commercial Insurance Application - Applicant Information Section 2002/9 126 Commercial General Liability Section (7/03) 2000/4 127 Business Auto Section (8/03) 2003/8 128 Garage and Dealers Section 2002/ Vehicle Schedule (8/03) 2003/8 130 WORKERS COMPENSATION APPLICATION (9/03) 2002/9 131 Umbrella Section (8/03) 2000/7 132 Truckers/Motor Carriers Section 1998/1 137 AL Alabama Commercial Auto - Coverages/Limits Section 1997/2 137 AK Alaska Commercial Auto - Coverages/Limits Section 1997/4 137 AZ Arizona Commercial Auto - Coverages/Limits Section 1997/3 137 AR Arkansas Commercial Auto - Coverages/Limits Section 2000/4 137 AE Armed Forces Europe Commercial Auto - Coverages/Limits Section 1900/1 137 AP Armed Forces Pacific Commercial Auto - Coverages/Limits Section 1900/1 137 CA California Commercial Auto - Coverages/Limits Section 1996/1 137 CO Colorado Commercial Auto - Coverages/Limits Section 1997/1 137 CT Connecticut Commercial Auto - Coverages/Limits Section 1996/1 137 DE Delaware Commercial Auto - Coverages/Limits Section 1996/3 137 DC District Of Columbia Commercial Auto - Coverages/Limits Section 1999/4 137 FL Florida Commercial Auto - Coverages/Limits Section (10/03) 2000/7 137 GA Georgia Commercial Auto - Coverages/Limits Section 1996/1 137 HI Hawaii Commercial Auto - Coverages/Limits Section 1998/ ID Idaho Commercial Auto - Coverages/Limits Section 1996/1 137 IL Illinois Commercial Auto - Coverages/Limits Section 1996/1 137 IN Indiana Commercial Auto - Coverages/Limits Section 2000/8 137 IA Iowa Commercial Auto - Coverages/Limits Section 1997/2 137 KS Kansas Commercial Auto - Coverages/Limits Section 1996/1 137 KY Kentucky Commercial Auto - Coverages/Limits Section 1996/1 137 LA Louisiana Commercial Auto - Coverages/Limits Section 1998/6 137 ME Maine Commercial Auto - Coverages/Limits Section 2000/4 137 MD Maryland Commercial Auto - Coverages/Limits Section 2000/5 137 MA Massachusetts Commercial Auto - Coverages/Limits Section 2000/9 137 MI Michigan Commercial Auto - Coverages/Limits Section 1996/3 137 MN Minnesota Commercial Auto - Coverages/Limits Section 2000/9 137 MS Mississippi Commercial Auto - Coverages/Limits Section 1996/1 137 MO Missouri Commercial Auto - Coverages/Limits Section 1996/1 137 MT Montana Commercial Auto - Coverages/Limits Section 1996/1
4 137 NE Nebraska Commercial Auto - Coverages/Limits Section 1997/8 137 NV Nevada Commercial Auto - Coverages/Limits Section 1996/1 137 NH New Hampshire Commercial Auto - Coverages/Limits Section 1996/1 137 NJ New Jersey Commercial Auto - Coverages/Limits Section 2002/8 137 NM New Mexico Commercial Auto - Coverages/Limits Section 1996/1 137 NY New York Commercial Auto - Coverages/Limits Section 2002/8 137 NC North Carolina Commercial Auto - Coverages/Limits Section 1996/1 137 ND North Dakota Commercial Auto - Coverages/Limits Section 2000/7 137 OH Ohio Commercial Auto - Coverages/Limits Section 1998/4 137 OK Oklahoma Commercial Auto - Coverages/Limits Section 1996/1 137 ON Ontario Commercial Auto - Coverages/Limits Section 1900/1 137 OR Oregon Commercial Auto - Coverages/Limits Section 2000/7 137 PA Pennsylvania Commercial Auto - Coverages/Limits Section 1996/1 137 PR Puerto Rico Commercial Auto - Coverages/Limits Section 1900/1 137 RI Rhode Island Commercial Auto - Coverages/Limits Section 1996/1 137 SC South Carolina Commercial Auto - Coverages/Limits Section 2002/8 137 SD South Dakota Commercial Auto - Coverages/Limits Section 1997/2 137 TN Tennessee Commercial Auto - Coverages/Limits Section 1996/1 137 TX Texas Commercial Auto - Coverages/Limits Section 2000/8 137 UT Utah Commercial Auto - Coverages/Limits Section 1997/2 137 VT Vermont Commercial Auto - Coverages/Limits Section 1996/1 137 VI Virgin Islands Commercial Auto - Coverages/Limits Section 1900/1 137 VA Virginia Commercial Auto - Coverages/Limits Section 1998/ WA Washington Commercial Auto - Coverages/Limits Section 2002/8 137 WV West Virginia Commercial Auto - Coverages/Limits Section 1996/1 137 WI Wisconsin Commercial Auto - Coverages/Limits Section 1996/3 137 WY Wyoming Commercial Auto - Coverages/Limits Section 1996/1 138 AL Alabama Coverages/Limits Section 1997/2 138 AK Alaska Coverages/Limits Section 1997/4 138 AZ Arizona Coverages/Limits Section 1997/3 138 AR Arkansas Coverages/Limits Section 2000/ AE Armed Forces Europe Coverages/Limits Section 1900/1 138 AP Armed Forces Pacific Coverages/Limits Section 1900/1 138 CA California Coverages/Limits Section 1996/3 138 CO Colorado Coverages/Limits Section 1997/1 138 CT Connecticut Coverages/Limits Section 1996/3 138 DE Delaware Coverages/Limits Section 1997/3 138 DC District Of Columbia Coverages/Limits Section 2000/9 138 FL Florida Coverages/Limits Section 2000/7 138 GA Georgia Coverages/Limits Section 2001/2 138 HI Hawaii Coverages/Limits Section 2001/2 138 ID Idaho Coverages/Limits Section 1996/3 138 IL Illinois Coverages/Limits Section 1996/3 138 IN Indiana Coverages/Limits Section 2000/8 138 IA Iowa Coverages/Limits Section 2001/8 138 KS Kansas Coverages/Limits Section 2002/7 138 KY Kentucky Coverages/Limits Section 2000/9 138 LA Louisiana Coverages/Limits Section 1998/6 138 ME Maine Coverages/Limits Section 2000/9 138 MD Maryland Coverages/Limits Section 2000/7
5 138 MA Massachusetts Coverages/Limits Section 2000/9 138 MI Michigan Coverages/Limits Section 1996/4 138 MN Minnesota Coverages/Limits Section 2001/ MS Mississippi Coverages/Limits Section 2002/9 138 MO Missouri Coverages/Limits Section 1996/3 138 MT Montana Coverages/Limits Section 2001/8 138 NE Nebraska Coverages/Limits Section 1997/8 138 NV Nevada Coverages/Limits Section 1996/3 138 NH New Hampshire Coverages/Limits Section 1996/3 138 NJ New Jersey Coverages/Limits Section 2002/8 138 NM New Mexico Coverages/Limits Section 1996/3 138 NY New York Coverages/Limits Section 2000/8 138 NC North Carolina Coverages/Limits Section 2000/9 138 ND North Dakota Coverages/Limits Section 2000/7 138 OH Ohio Coverages/Limits Section 2002/1 138 OK Oklahoma Coverages/Limits Section 1996/3 138 ON Ontario Coverages/Limits Section 1900/1 138 OR Oregon Coverages/Limits Section 2000/7 138 PA Pennsylvania Coverages/Limits Section 2002/7 138 PR Puerto Rico Coverages/Limits Section 1900/1 138 RI Rhode Island Coverages/Limits Section 2001/3 138 SC South Carolina Coverages/Limits Section 2002/8 138 SD South Dakota Coverages/Limits Section 1997/2 138 TN Tennessee Coverages/Limits Section 2002/1 138 TX Texas Coverages/Limits Section 2000/8 138 UT Utah Coverages/Limits Section 2001/1 138 VT Vermont Coverages/Limits Section 2001/1 138 VI Virgin Islands Coverages/Limits Section 1900/1 138 VA Virginia Coverages/Limits Section 2001/8 138 WA Washington Coverages/Limits Section 2002/8 138 WV West Virginia Coverages/Limits Section 1996/3 138 WI Wisconsin Coverages/Limits Section 1996/4 139 Statement of Values forms 2000/7 140 Property Section 2000/7 141 C Crime Section /3 143 Transportation Section 1991/9 144 Glass Policy 1994/ Equipment Floater (9/03) 2000/5 147 Installation Builders Risk 2002/2 148 Electronic Data Processing Section 2000/2 159 Schedule of Insurance 2000/7 160 Business Owners Application 2000/8 163 Commercial Auto Driver Information Schedule 1998/1 175 Commercial Auto Change Request ACORD (8/03) 2001/4 175 SC South Carolina Commercial Auto Change Request ACORD 1999/2 185 Restaurant/Tavern Supplement 2001/2 186 Contractors Supplement 2002/1 187 Professional Liability Supplement 1998/3 194 Truckers/Motor Carrier Supplement 1998/1 301 Flood Insurance Application (New) Pending 1997/3
6 303 Flood Insurance Preferred Risk Policy (New) Pending 2002/9 302 Flood Insurance General Change Endorsement (New) Pending 3/ Flood Insurance Cancellation/Nullification (New) Pending 3/97
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