Acord Forms Index
All packages contain 100 forms - Please specify number of packages required
E-Mail Address:
ACORD Account #:
Zip:State:
Contact Name:
Web Site:
Fax:
Telephone:
City:
Street Address:
Agency/Company Name:
Please provide the information below to avoid delay in shipment.
ACORD Forms Index
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
Page 1 of 12
COUNTRYWIDE P&C FORMS
1
2
3
4
11
12
13
23
24
25
26
27
35
36
37
42
45
50
50 WM
54
57
60
60 US
2013/01 Property Loss Notice
Automobile Loss Notice
General Liability Notice of Occur/Claim
Workers Compensation - First Report of Injury or Illness
Auto Accident Information Form2/95
Exchange of Information Form
Witness Card
2/95
2/95
Vehicle or Equipment Certificate of Insurance
Certificate of Property Insurance2009/09
Certificate of Liability Insurance
Policy Certification Log2002/01
Evidence of Property Insurance
Cancellation Request / Policy Release2011/09
Agent/Broker of Record Change
Statement of No Loss2008/01
Residential Property Replacement Cost
Additional Interest Schedule2009/04
Automobile Insurance ID Card2007/02
Financial Responsibility Form1/97
Insurance Supplement - Notice - Offer of Terrorism Coverage
1/97
Flood Insurance Selection / Rejection2010/04
Automobile Insurance ID Card (with Watermark)2007/03
Financial Responsibility Form - Cancellation
2015/01
62 US
Insurance Supplement - Standard Fire Policy Only
Notice - Offer of Terrorism Coverage
63 Fraud Statements
92
93
125
126
127
128
129
Medical Statement
Young Driver Questionnaire
Commercial Insurance Application
Applicant Information Section
Commercial General Liability Section
Business Auto Section
Garage and Dealers Section
Vehicle Schedule
28 Evidence of Commercial Property Insurance
22 Intermodal Interchange Certificate of Insurance
2007/01
58 2007/11 Notice of Cancellation or Termination of Policy
99 Accidents / Convictions Schedule
103
Personal Auto Application Schedule - Additional Resident
and Driver Information Section
101 Additional Remarks Schedule2008/01
2009/11
2009/02
82
83
Watercraft Application
Personal Umbrella Application
91 Good Student Driver Training
88
Personal Insurance Application - Applicant Information
Section
89 Residential Section
5 Aircraft Loss Notice
6 Aviation Witness / Passenger Schedule
7 Aviation Injured Schedule
2009/05
2009/05
20 Certificate of Aviation Liability Insurance2009/12
21 Certificate of Aircraft Insurance
2009/10
2009/12
2012/04
2010/05
2009/12
106 Vacant Building Supplement2010/04
105 Apartment Building Supplement2012/06
80 Homeowner Application
29 Evidence of Flood Insurance
76 Binder Log9/93
30 Certificate of Garage Insurance
75 Insurance Binder2013/09
74
Residence Based Business
Supplement to Residential Section
2009/09
84 Dwelling Fire Application
2012/03
2012/03
2012/03
81 Personal Inland Marine Application
85 Mobile Home Application
73 Solid Fuel Questionnaire - Supplement to Residential Section2009/07
31 Certificate of Marine / Energy Insurance
2013/01
2013/01
2013/01
2013/01
72 Mobile Home Supplement2009/10
38 2013/01 Notice of Insurance Information Practices (Privacy)
71 Personal Auto Policy Change Request2012/03
2014/01
2014/01
2014/01
2014/01
2013/09
2013/09
2013/09
2013/09
2013/09
2013/09
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
66
Personal Insurance Supplement - Extraordinary Life
Circumstances
2011/05
Insurance Supplement - Workers' Compensation Only
Notice - Offer of Terrorism Coverage
64 US
2013/09145 Accounts Receivable / Valuable Papers
131
132
133
139
140
141
Umbrella Section
Truckers / Motor Carriers Section
Workers Compensation Insurance Plan - Assigned Risk
Section
Statement / Schedule of Values
Property Section
Crime Section 2000
2014/09
2015/06
2013/09
2013/09144 Glass And Sign Section
143 Transportation Section
130 Workers Compensation Application2013/09
# Current Title Quantity Current Title QuantityFuture # Future
2013/10
70 Personal Policy Change Request (Except Auto)2012/03
68 Electronic Delivery Supplement2013/08
2013/12
ACORD Forms Index (rev. 09-30-2015)
2014/042014/08
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2015/01
2015/01
2015/12
2015/12
2015/12
2013/09147 Installation / Builders Risk Section
2015/09
2015/09
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2015/12
2016/03
2016/03
2015/12
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
All packages contain 100 forms - Please specify number of packages required
ACORD Forms Index
Page 2 of 12
Hotel / Motel Supplement
2009/04 Premium Payment Supplement
2011/09
2002/01 Railroad Protective Liability Supplement
Agriculture Property Section
Agriculture Application
Watermark Paper - 32 # ID Card Stock (non-perforated)
Watermark Paper - 32 # ID Card Stock (4-part perforation)
Watermark Paper - 20 # ID Card Stock (4-part perforation)
3/93 Statement of Premium Adjustment
1/98 Policyholder's Report
3/93 Producer Account Discrepancy Notice
802
801
610
402
401
370
360
350
226
225
201
COUNTRYWIDE P&C FORMS - continued
Yacht Section210
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
Directors & Officers Liability Section807
10/96 Design Professional's Individual Property Survey195
2009/03 Truckers / Motor Carrier Supplement194
3/93 Producer Account
1/99 Application Supplement - Undertaking
200
199
Medical Professional Liability Insurance Application196
2009/05 Aviation Insurance Binder275
2009/05 Aircraft Insurance Binder276
Pilot Experience Change Request341
Hangar Change Request342 2009/06
Open Cargo Section193
Employment Related Practices Liability Section188
Professional Liability Supplement187 3/98
Personal Umbrella Application Section283
Contractors Supplement186
Surety Report of Execution501 2004/07
Small Farm / Ranch Application410
Liquor Liability Section803
2011/10
2011/11
Personal Inland Marine Section281
Equine Liability Supplement408 2007/09
Restaurant / Tavern Supplement2011/09185
Livestock Mortality Section407
Errors and Omissions Section - Electronic Data Processors,
Electronic Products Manufacturers, Computer Services etc.
180
Agriculture Premises Diagram405 2007/09
Agriculture Supplement - Unscheduled Farm Personal
Property Inventory Form
406 2007/09
282 Watercraft Section
Commercial Policy Change Request175 2012/04
Agriculture Liability Section404
163 Commercial Auto Driver Information Schedule2012/06
Agriculture Property Section
Scheduled / Unscheduled Personal Property
403
160 Business Owners Section
2013/09
2013/09
2013/09
2013/09
Supplemental Property Application190
149
155 BM
159
Dealers Section
Boiler & Machinery Section 2002
Schedule of Insurance2014/09
2013/09
2013/09
2013/09
National Flood Insurance Program
Flood Insurance Application
301
International Liability Exposure Supplement815
2005/06 International Property Exposure Supplement816
2009/02
2005/03 Request for Proof of Property Insurance813
2006/02 Agency Questionnaire812
Value Reporting Information Supplement to Property Section811
Business Income / Extra Expense / Rental Value
Supplement to Property Section
810
P&C Agency Appointment Form808 2010/08
# Current Title Quantity Current Title QuantityFuture # Future
2013/09148 Electronic Data Processing Section
2015/04
NFIP - Flood Insurance Preferred Risk Policy Application
NFIP - Flood Insurance Cancellation / Nullification
NFIP - Flood Insurance General Change Endorsement
304
303
302
Aviation Insurance Application - Applicant Information Section
NFIP - Credit Card Payment Form305
NFIP - Rating Information and Elevated Building
Determination Form
306 2011/04
NFIP - Floodproofing Certificate for Non-Residential
Structures
307
NFIP - Residential Basement Floodproofing Certificate308
2012/02
2013/09325
2015/04
Aviation Policy Change Request – Applicant Information
Section
335 2009/06
2006/04 Airport Property Supplement326
Airport and FBO Liability Section327
Private Hangar Liability Section328
Aviation Products Liability329
Aircraft Section330
Pilot Experience331
2006/04 Hangar Schedule332
2011/11
2009/05 Aircraft Schedule333
Airport Property Change Request336
Airport and FBO Liability Change Request337
Private Hangar Liability Change Request338
Aviation Products Liability Change Request339
2009/06
2009/06
2009/06
2009/06
Professional / Specialty Insurance Application - For Use in
Management, Executive & Professional Lines
Applicant Section
825
Driver Work / School Address Information Supplement822
Additional Premises Information Schedule823 2011/10
2009/07
Producer Information Form (PIF)821
2013/09
Employment Practices Liability Insurance Section827
Fiduciary Liability Coverage Section828
Forms and Endorsements Schedule829 2009/05
Property Insurance Card830 2008/11
Professional / Specialty Insurance Notice of Incident / Claim831
Miscellaneous E&O Section832
Lawyers Professional Liability Section833
Cyber and Privacy Coverage Section834
2013/01
Aircraft Change Request340 2009/06
Accountants Professional Liability Section838 2013/12
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
2014/12
2015/06
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2015/10
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
Contract Bond Request Form502 2015/04
2015/04
2015/04
2015/04
2015/04
152 Commercial Inland Marine Section2015/06
2015/07 Claims History / Loss Run Request611
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2016/03
2015/12
ACORD Forms Index (rev. 09-30-2015)
Background Check Authorization876 2015/10
Disclosure of Intent to Obtain Consumer Report or
Investigative Consumer Report (except California)
877 2015/10
Page 3 of 12
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS
61 CT
66 CT
90 CT
137 CT
138 CT
171 CT
172 CT
173 CT
Connecticut Auto Supplement - UM Coverage2010/01
Connecticut FAIR Plan Application for Property / Liability
Insurance
2015/02
Connecticut Personal Auto Application
Connecticut Commercial Auto
Connecticut Garage and Dealers
Connecticut Workers' Comp. Comm. - Coverage Election
by Employee Who Is an Officer of a Corporation, Manager
of an LLC, or Member of a Multiple-Member LLC
Connecticut
Connecticut Workers' Comp. Comm. - Coverage Election
by Employees who are Members of a Partnership
Connecticut Workers' Comp. Comm. - Coverage Election
by Sole Proprietor or Single-Member LLC
2006/08
2006/08
2006/08
50 CT Connecticut Insurance Identification Card2009/01
290 CT Connecticut Personal Automobile Application Section
62 CT
Connecticut Personal Insurance Supplement - Summary of
Consumer Protections
2011/07
2001/0261 AZ Arizona Auto Supplement UM/UIM Coverage Selection
2003/1038 AZ Arizona Notice of Information Practices (Privacy)
Arizona
Arizona Garage and Dealers
Arizona Commercial Auto
Arizona Personal Auto Application
138 AZ
137 AZ
90 AZ
2012/0850 AZ Arizona Insurance Identification Card
Arizona Personal Automobile Application Section290 AZ
Arkansas
90 AR
137 AR
138 AR
Arkansas Personal Auto Application
Arkansas Commercial Auto
Arkansas Garage and Dealers
67 AR 2000/02
Arkansas Property Supplement - Declination of
Residential Earthquake Coverage
Arkansas Proof of Insurance Card50 AR
61 AR 2010/04 Arkansas Auto Supplement UM/UIM Coverage
2007/10
290 AR Arkansas Personal Auto Application Section
62 AR 2013/09 Arkansas Personal Umbrella Supplement
6/98 Alaska Petition For Executive Officer Waiver171 AK
Alaska
Alaska Garage and Dealers
Alaska Commercial Auto
Alaska Personal Auto Application
2/98 Alaska Auto Supplement - Exclusion of Named Drivers
7/97 Alaska Auto Supplement - UM/UIM Coverage Selection
138 AK
137 AK
90 AK
62 AK
61 AK
Alaska Personal Auto Application Section290 AK
138 AL
Alabama Personal Auto Application
Alabama
62 AL Alabama Insurance Application Supplement5/98
90 AL
Alabama Commercial Auto137 AL
Alabama Garage and Dealers
50 AL Alabama Insurance Identification Card2007/10
Alabama Personal Automobile Application Section290 AL
61 CO
90 CO
137 CO
138 CO
171 CO
Colorado Auto Supplement - Summary of Coverages
Colorado Personal Automobile Application
Colorado Commercial Auto
Colorado Garage and Dealers
Colorado Rejection of Coverage by Corporate Officers2006/01
Colorado
50 CO Colorado Insurance Identification Card2007/03
2012/01
64 CO
Colorado Auto Supplement - Colorado Offer of Medical
Payments Coverage
2009/01
290 CO Colorado Personal Automobile Application Section
65 CO
Colorado Personal Property Supplement - Summary of
Coverage Renters Policy
2013/02
66 CO
Colorado Personal Property Supplement - Summary of
Coverage Condominium Policy
2013/02
67 CO
Colorado Personal Property Supplement - Summary of
Coverage Dwelling Fire Policy
2013/02
68 CO
Colorado Personal Property Supplement - Summary of
Coverage Homeowners Policy
2013/02
61 CA
64 CA
65 CA
66 CA
67 CA
68 CA
California Auto Supplement - Mandatory UM Bodily Injury /
Property Damage Coverage Offer
California Insurance Supplement - Agency Language
California Insurance Supplement - Race, National Origin,
Gender
California Offer of Earthquake Coverage2011/04
California Residential Property Insurance Disclosure
2001/03
California Scheduled Personal Property Loss Computation
Disclosure
California
2004/02
2004/07
50 CA California Insurance Identification Card2004/07
51 CA California Evidence of Liability Insurance2004/07
52 CA California Fleet Auto Insurance Identification Card2007/07
2008/03
2011/07
2013/10
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
California (continued)
861 CA 2011/07 California Residential Property Insurance Bill of Rights
860 CA California Auto Supplement - Driver Self Certification2004/12
857 CA
California Earthquake Authority - Application for
Earthquake Insurance
2011/02
# Current Title Quantity Current Title QuantityFuture # Future
856 CA
California FAIR Plan Property Insurance - Application for
Businessowners (BOP) Insurance
69 CA California Insurance Supplement
Arkansas Accountants Professional Liability Section838 AR 2013/12
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
69 CO
Colorado Personal Property Supplement - Homeowner's
Insurance Replacement-Cost Policy Applicants
2014/01
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
855 CA
California FAIR Plan Property Insurance - Application for
Commercial Insurance
Arkansas Employment Related Practices Liability Section188 AR 2014/12
90 CA
137 CA
138 CA
177 CA
California Personal Auto Application
California Commercial Auto
California Garage and Dealers
California Auto Body Repair Consumer Bill of Rights2015/09
854 CA
California FAIR Plan Property Insurance - Application for
Dwelling Insurance
290 CA California Personal Auto Application Section
2014/12
2014/12
2014/12
2014/12
Arkansas Directors & Officers Liability Section807 AR 2014/12
Arkansas Employment Practices Liability Insurance Section827 AR 2014/12
Arkansas Fiduciary Liability Coverage Section828 AR 2014/12
Arkansas Miscellaneous E&O Section832 AR 2014/12
Arkansas Lawyers Professional Liability Section833 AR 2014/12
Arkansas Cyber and Privacy Coverage Section834 AR 2014/12
2015/01
2015/01
2015/01
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
ACORD Forms Index (rev. 09-30-2015)
California Disclosure of Intent to Obtain an Investigative
Consumer Report
877 CA 2015/10
Page 4 of 12
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
# Current Title Quantity Current Title QuantityFuture # Future
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
Delaware Executive Officer(s) Exclusion171 DE 2006/01
Delaware
137 DE Delaware Commercial Auto
Delaware Personal Auto Application
FAIR Plan Supplementary Questionnaire
90 DE
65
PA / DE
/ WV
Delaware Garage and Dealers138 DE
Insurance Placement Facility of Delaware
Basic Property Insurance Application
2015/0564 DE
Automobile Insurance ID Card (with Watermark)
2006/10
DE Auto Supplement, DE Motorist's Protection Act
Required Statement to Policyholders
2007/03
61 DE
50 WM
62 DE 2004/10 DE Auto Supplement, PIP Deductible Options
38 DE
Delaware Personal Insurance Supplement
Notice of Information Practices (Privacy)
2008/04
Delaware Personal Auto Application Section290 DE
67 DE 2012/01 Delaware Insurance Supplement
2013/12
2013/12
2013/12
2014/12
Florida Insurance Supplement
Credit Report Disclosure Information
Florida Homeowners Supplement67 FL 7/94
66 FL
Citizens Property Ins Corp, Wind Only - Supplemental
Application Schedule Commercial and Commercial -
Residential
2002/07
Florida Garage and Dealers
Florida Commercial Auto
Florida Personal Auto Application
Florida
3/97 Florida Workers Compensation Monthly Change Sheet
Florida Revocation of Election to be Exempt
Florida Notice of Election of Coverage
2013/03 Florida Workers Comp. Addendum to ACORD 130 FL
2015/02 Florida Workers Compensation Application
221 FL
175 FL
172 FL
171 FL
138 FL
137 FL
133 FL
130 FL
90 FL
Florida Auto Supplement - Rejection/Election of UM
Coverage
61 FL
Florida Personal Auto ID Card50 FL
2014/10
2007/08
174 FL Florida Revocation of Election of Coverage
Florida Residential Property Supplement65 FL 2007/08
2007/08
Florida Commercial Auto ID Card51 FL
Florida Auto Supplement - Personal Injury Protection Options62 FL
Florida Auto Supplement - Notice to Policyholders - Florida
Notification of Availability of Uninsured Motorist Coverage
64 FL
2009/07
2009/07
2011/10
2011/10
Florida Commercial Insurance Application
Applicant Information Section
125 FL
Florida Commercial Auto Addendum860 FL 2011/11
Florida Property Supplement
Uniform Mitigation Verification Inspection Form
2012/0270 FL
District of Columbia Garage and Dealers138 DC
District of Columbia Commercial Auto137 DC
District of Columbia Personal Auto Application90 DC
District of Columbia
64 DC
Application to District of Columbia Property Insurance Facility
for Basic Property Insurance
67 DC
66 DC
District of Columbia Property Insurance Facility - Essential
Homeowners Ins. Inspection and Placement Application p. 1
District of Columbia Property Ins. Facility - Essential
Homeowners Ins. Inspection and Placement Application p. 2
District of Columbia Personal Auto Application Section290 DC
2013/10
2013/10
2013/10
68 DC
District of Columbia Personal Property Supplement, Statement
Regarding Sewer-line Backup Insurance
2013/09
62 DC
District of Columbia Personal Property Supplement, Statement
Regarding Flood Insurance
2013/09
2013/12
2013/12
2013/12
2013/12
Florida Personal Auto Supplement862 FL
Florida Personal Auto Supplement863 FL
2013/12
2013/12
2014/01
2014/12
2014/12
2014/12
2014/12
Florida (continued)
83 FL Florida Personal Umbrella Application2014/12
283 FL Florida Personal Umbrella Application Section2014/12
90 GA
137 GA
138 GA
171 GA
Georgia State Board of Workers' Compensation - Notice of
Election or Rejection of Workers' Compensation Coverage
2013/05
Georgia
Georgia Personal Auto Application
Georgia Commercial Auto
Georgia Garage and Dealers
50 GA 2008/11 Georgia Insurance Policy Information Card
51 GA 2005/01 Georgia Fleet Policy Information Card
64 GA
Georgia Auto Supplement - Georgia Auto Disclosure Form,
Notice to Policyholders, Uninsured Motorist Coverage
Selection
2009/01
290 GA Georgia Personal Automobile Application Section
2014/12
2014/12
2014/12
2014/12
Citizens Property Insurance Corporation
Commercial - Residential Wind Only
2012/12220 FL
2015/02
2015/12
2015/12
2015/05
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2016/03
ACORD Forms Index (rev. 09-30-2015)
Page 5 of 12
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS - continued
2/9862 IA Iowa Auto Supplement - Notice Regarding UM/UIM Coverage
2002/0261 IA Iowa Auto Supplement - UM/UIM Offer/Rejection
2007/0850 IA Iowa Financial Responsibility Card
Iowa
2008/0165 IA Iowa Auto Supplement - Aftermarket Crash Parts
2/9864 IA Iowa Auto Supplement - UM/UIM Stacking Coverage Notice
Iowa Personal Auto Application90 IA
Iowa Garage and Dealers
Iowa Commercial Auto
138 IA
137 IA
2006/0766 IA
Iowa Personal Insurance Supplement
Disclosure Use of Claims History
2010/0767 IA
Iowa Personal Insurance Supplement
Extraordinary Life Circumstances Disclosure
290 IA Iowa Personal Automobile Application Section
Indiana
90 IN
137 IN
138 IN
Indiana Personal Auto Application
Indiana Commercial Auto
Indiana Garage and Dealers
50 IN 2007/11 Indiana Insurance Identification Card
290 IN Indiana Personal Auto Application Section
90 IL
137 IL
138 IL
Illinois Personal Auto Application
Illinois Commercial Auto
Illinois Garage and Dealers
Illinois
171 IL
Illinois FAIR Plan Application for Commercial Property
Insurance
2005/06
Illinois Auto Supplement - UM/UIM61 IL
Illinois Property Supplement - Notice of Availability of
Earthquake Insurance
62 IL
Illinois Insurance Identification Card50 IL 2007/03
2007/08
290 IL Illinois Personal Auto Application Section
Illinois Insurance Supplement - Civil Union Disclosure67 IL 2012/01
Hawaii Garage and Dealers
Hawaii Commercial Auto
Hawaii
138 HI
137 HI
Hawaii Personal Auto Application
2001/03 Hawaii Vehicle Inspection Report Supplement94 HI
90 HI
2010/07 Hawaii Auto Supplement - UM/UIM/PIP60 HI
2008/01 Hawaii Auto ID Card50 HI
Hawaii Personal Auto Application Section290 HI
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
Idaho Commercial Auto
Idaho Garage and Dealers
137 ID
138 ID
Idaho
90 ID Idaho Personal Auto Application
50 ID State of Idaho Liability Insurance Identification Card2007/10
61 ID
Idaho Auto Supplement - Idaho Uninsured Motorist and
Underinsured Motorist Disclosure Statement
2009/01
290 ID Idaho Personal Automobile Application Section
# Current Title Quantity Current Title QuantityFuture # Future
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2015/01
Kansas Cancel. of Election of Coverage for Volunteer
Workers
Kansas Cancellation of Election of Employer to Cover
Employees
Kansas Election Not to Accept Coverage
Kansas Cancellation of Election Not to Accept Coverage
Kansas Garage and Dealers
Kansas Commercial Auto
Kansas Personal Auto Application
138 KS
137 KS
90 KS
Kansas
Kansas Election of Coverage for Persons Performing Public
Service
Kansas Election of Coverage for Volunteer Workers
Kansas Election of Employer to Cover Employees
2005/11
Kansas Cancel. of Elec. of Individual, Partner or
Self-Employed Individual
2005/11
Kansas Elec. of Individual, Partner or Self-Employed
Individual
180 KS
179 KS
178 KS
177 KS
176 KS
174 KS
173 KS
172 KS
171 KS
2005/11
38 KS
Kansas Personal Insurance Supplement - Notice of
Insurance Information Practices
2005/11
2005/11
2005/11
2005/11
2005/11
2005/11
Kansas Cancellation of Election of Coverage for Persons
Performing Public Service
181 KS 2005/11
Kansas Cancellation of Election of a Noncompensated
Volunteer to be Covered
2001/05183 KS
2001/05
Kansas Election of a Noncompensated Volunteer to be
Covered
182 KS
Kansas Personal Auto Application Section290 KS
2013/12
2014/12
2014/12
2014/12
2014/12
138 KY Kentucky Garage and Dealers
Kentucky
90 KY
137 KY
Kentucky Personal Auto Application
Kentucky Commercial Auto
50 KY Commonwealth of Kentucky Proof of Insurance2006/01
64 KY Kentucky FAIR Plan Homeowners Application2011/01
65 KY Kentucky FAIR Plan Dwelling Fire Application2011/01
66 KY Kentucky FAIR Plan Farm Fire Application2011/01
68 KY Kentucky FAIR Plan Commercial Fire Application2011/01
290 KY Kentucky Personal Auto Application Section
2014/12
2014/12
2014/12
2014/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/09
2015/09
2015/09
2015/09
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence
Property Insurance Supplement
67 2015/07
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence
Property Insurance Supplement
67 2015/07
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence
Property Insurance Supplement
67 2015/07
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
60 KY
Kentucky Auto Supplement - Rejection of Uninsured /
Underinsured Motorist Coverage
2015/09
ACORD Forms Index (rev. 09-30-2015)
Page 6 of 12
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS - continued
Maryland Personal Auto Application90 MD
Maryland Property Insurance Availability Program - Essential
Homeowners Insurance Inspection and Placement (p. 2 of 2)
Maryland Commercial Auto Supplement62 MD 1/98
Maryland Application Supp Notice of Intent to Use Credit
History
39 MD
66 MD
Maryland
Maryland Property Insurance Availability Program - Essential
Homeowners Insurance Inspection and Placement (p. 1 of 2)
65 MD
Maryland Property Insurance Availability Program
Essential Property Insurance Inspection and Placement
64 MD
Maryland Garage and Dealers138 MD
Maryland Commercial Auto137 MD
2003/05
Maryland Personal Auto Supplement - Mandatory Offer of
Increased Liability Coverage for Claims of Family Members,
Mandatory PIP Waiver, and Mandatory UM Coverage Waiver
67 MD 2011/01
Maryland Personal Property Supplement - Statement
Regarding Flood Insurance
68 MD 2007/01
Maryland Insurance Supplement - Notice of Underwriting
Period
69 MD
Maryland Personal Property Supplement - Loss from Water
and Sewer Backup
851 MD 2008/11
290 MD Maryland Personal Automobile Application Section
Maryland Personal Property Supplement - Homeowner's
Insurance, Limitation of Claims Made Notice
852 MD 2012/10
2013/10
2013/10
2013/10
2013/10
Maine
90 ME Maine Personal Auto Application
137 ME Maine Commercial Auto
138 ME Maine Garage and Dealers
50 ME Maine Motor Vehicle Insurance Identification Card2007/08
290 ME Maine Personal Auto Application Section
Louisiana Commercial Auto137 LA
138 LA Louisiana Garage and Dealers
Louisiana
90 LA Louisiana Personal Auto Application
66 LA
68 LA
4/98
4/98 Louisiana Plan Services Application for Insurance
Louisiana Dwelling Supplement - Loss Settlement DWG2 & 3
67 LA 5/98 Louisiana Certification of Mobile Home Tie Downs
61 LA
62 LA
64 LA
65 LA
Louisiana Homeowners Supplement - Loss Settlement (HO4)2001/05
Louisiana Commercial Property Supplement4/98
2001/02
Louisiana Homeowners Supplement
Loss Settlement (HO2 & 3)
2001/05
Louisiana Homeowners Supplement - Loss Settlement (HO6)
60 LA Louisiana Dwelling Supplement - Loss Settlement DWG14/98
50 LA Louisiana Auto ID Card2008/03
2005/07861 LA
Louisiana Auto Supplement - Active Military Personnel
Affidavit
2009/06862 LA
Louisiana Property Supplement - Hurricane Loss Mitigation
Survey
290 LA Louisiana Personal Auto Application Section
Massachusetts Property Insurance Underwriting Association
Instructions to Complete Homeowners Application ACORD 60
MA
2003/04
Massachusetts Property Insurance Underwriting Association
Application for Homeowners Insurance
Massachusetts
61 MA
60 MA
Massachusetts Garage and Dealers138 MA
Massachusetts Renewal Application (Statement of Facts)95 MA
2012/02
Application for Massachusetts Motor Vehicle Insurance90 MA
Massachusetts Commercial Auto137 MA
Massachusetts Property Ins Underwriting Assn - Instructions
for Completing Dwelling Fire and Liability Insurance
Application ACORD 65 MA
66 MA
2009/12
Massachusetts Property Ins Underwriting Assn - Application
for Commercial Fire Insurance Inspection and Placement
2003/0467 MA
Massachusetts Property Insurance Underwriting Association
Inspection Notice, Credit Reporting Notice and Instructions
for Completing Commercial Fire Application ACORD 67 MA
2003/0468 MA
Massachusetts Residential Property Liquid Fuel Spill
Supplement
69 MA 2010/07
Massachusetts Property Insurance Underwriting Association
Application for Dwelling Fire and Liability Insurance
Inspection and Placement
65 MA
Massachusetts Residential Property Liability Supplement
Lead Poisoning Liability Disclosure Notice
2/9764 MA
2012/02
2012/07
2015/01
2012/08
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
# Current Title Quantity Current Title QuantityFuture # Future
853 MD Maryland Personal Property Supplement2014/01
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
Michigan WC Placement Facility Specific Person Exclusion
4/96
Michigan
Michigan Application for Exclusion of Partner(s), Spouse,
Child or Parent
Michigan Notice of Election
Michigan Automobile Insurance Placement Facility
Supplement to ACORD App. - Application for Commercial,
Public Automobiles and Corporately Owned Vehicles
2004/07
2000/09
2005/01
173 MI
172 MI
171 MI
139 MI
Michigan Garage and Dealers
Michigan Commercial Auto
138 MI
137 MI
Michigan Application for Workers' Compensation Insurance2012/08133 MI
Michigan Personal Auto Application
2014/03
Michigan Basic Property Insurance Assn Insurance
Application
2000/10
Michigan Collision Insurance Options Notice
2010/08 State of Michigan Certificate of No-Fault Insurance
90 MI
64 MI
62 MI
50 MI
2010/03
Michigan Automobile Insurance Placement Facility
Michigan Auto Supplement - Declaration of Intent to Reside
60 MI
2010/03 Michigan Auto Supplement - Declaration of Intent to Reside860 MI
Michigan Personal Automobile Application Section290 MI
2014/12
2014/12
2014/12
2014/12
2015/01
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
ACORD Forms Index (rev. 09-30-2015)
Page 7 of 12
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS - continued
50 MO
67 MO
Missouri Auto Insurance ID Card2007/05
Missouri FAIR Plan Insurance Application2009/06
90 MO
137 MO
138 MO
Missouri Personal Auto Application
Missouri Commercial Auto
Missouri Garage and Dealers
Missouri
Missouri Property Supplement - Notice of Availability of
Earthquake Insurance
62 MO 2007/08
290 MO Missouri Personal Auto Application Section
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
Montana Garage and Dealers
Montana Commercial Auto
Montana Personal Auto Application
138 MT
137 MT
90 MT
Montana
2003/0960 MT Montana Application Supplement - Refusal to Renew
290 MT Montana Personal Auto Application Section
Nevada Garage and Dealers
Nevada Commercial Auto
138 NV
137 NV
Nevada Umbrella Supplement2001/0562 NV
Nevada Personal Auto Application90 NV
Nevada Auto Supplement, Mandatory Offer of Medical
Payments Coverage and Uninsured Motorists Coverage
2002/1261 NV
Nevada
Nevada Temporary Insurance Identification Card51 NV
Nevada Permanent Insurance Identification Card52 NV
Nevada Personal Auto Application Section290 NV
Nevada Temporary Insurance Identification Card, Evidence
of Operator's Policy of Liability Insurance
53 NV
Nevada Permanent Insurance Identification Card, Evidence
of Operator's Policy of Liability Insurance
54 NV
2013/10
2013/10
2013/10
New Hampshire Garage and Dealers
New Hampshire Commercial Auto
New Hampshire Personal Auto Application
138 NH
137 NH
90 NH
New Hampshire
New Hampshire Personal Auto Application Section290 NH
Mississippi
Mississippi Auto Insurance ID Card2008/0150 MS
Mississippi Statement/Schedule of Values
Mississippi Garage and Dealers
Mississippi Commercial Auto
138 MS
137 MS
2/99139 MS
Mississippi Personal Auto Application90 MS
Mississippi Personal Auto Application Section290 MS
Mississippi Auto Supplement - Non-Stacking UM Insurance2013/0761 MS
New Jersey
136 NJ
New Jersey Workers Compensation Insurance Plan
Truckers Supplemental Request Form
134 NJ
New Jersey Workers Compensation Insurance Plan
Notice of Election - Proprietors and Partners
135 NJ
New Jersey Workers Compensation Insurance Plan
Employee Leasing Supplemental Request Form
132 NJ 2015/09
133 NJ
New Jersey Workers Compensation Insurance Plan
Notes and Instructions (Coverage Request Form)
New Jersey Workers Compensation Insurance Plan
Coverage Request Form
94 NJ Insurance Inspection Report2006/04
New Jersey Personal Auto Application90 NJ
68 NJ NJUIA Commercial Fire Application
62 NJ
64 NJ
New Jersey Auto Supplement - Basic Policy Coverage2006/10
2010/03 New Jersey Auto Supplement - Standard Policy Coverage
65 NJ 2003/02 New Jersey Property Insurance Supplement - Earthquake
67 NJ 2010/08 NJUIA Dwelling Fire Application
61 NJ New Jersey Auto Insurance Buyer's Guide
60 NJ
New Jersey Homeowners Insurance Supplement Flood
Exclusion
2001/10
50 NJ Temporary State of New Jersey Insurance Identification Card2005/05
51 NJ Permanent State of New Jersey Insurance Identification Card2007/06
2011/07
2010/05
138 NJ New Jersey Garage and Dealers
New Jersey Commercial Auto137 NJ
171 NJ
New Jersey Workers Compensation Insurance Plan - NJ
Workers Compensation and Employers Liability Manual
Part 3, Section 14
2003/07
New Jersey Personal Auto Application Section290 NJ
66 NJ
New Jersey Auto Insurance Buyer's Guide
Commercial PPA Edition
2011/07
Minnesota
Minnesota Authorization2013/0138 MN
Minnesota Auto Supplement2000/0162 MN
Minnesota Garage and Dealers
Minnesota Commercial Auto
138 MN
137 MN
Minnesota Personal Auto Application90 MN
Minnesota Personal Auto Application Section290 MN
Minnesota Insurance Guarantee Association Notice65 MN
Minnesota Homeowners Personal Property Supplement853 MN 2010/08
2012/04
# Current Title Quantity Current Title QuantityFuture # Future
2015/10
2013/10
Minnesota Accountants Professional Liability Section838 MN 2013/12
Montana Accountants Professional Liability Section838 MT 2013/12
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
Minnesota Employment Related Practices Liability Section188 MN 2014/12
Montana Employment Related Practices Liability Section188 MT 2014/12
Minnesota Directors & Officers Liability Section807 MN 2014/12
Minnesota Employment Practices Liability Insurance Section827 MN 2014/12
Minnesota Fiduciary Liability Coverage Section828 MN 2014/12
Minnesota Miscellaneous E&O Section832 MN 2014/12
Minnesota Lawyers Professional Liability Section833 MN 2014/12
Minnesota Cyber and Privacy Coverage Section834 MN 2014/12
Nebraska
90 NE
137 NE
138 NE
Nebraska Personal Auto Application
Nebraska Commercial Auto
Nebraska Garage and Dealers
50 NE 2007/01 Nebraska Auto Liability Insurance Identification Card
290 NE Nebraska Personal Auto Application Section
2014/12
2014/12
2014/12
2014/12
Montana Directors & Officers Liability Section807 MT 2014/12
Montana Employment Practices Liability Insurance Section827 MT 2014/12
Montana Fiduciary Liability Coverage Section828 MT 2014/12
Montana Miscellaneous E&O Section832 MT 2014/12
Montana Lawyers Professional Liability Section833 MT 2014/12
Montana Cyber and Privacy Coverage Section834 MT 2014/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/09
2015/09
2015/09
2015/09
ACORD Forms Index (rev. 09-30-2015)
2015/10
2015/10
2015/10
Page 8 of 12
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS - continued
North Carolina
138 NC North Carolina Garage and Dealers
137 NC North Carolina Commercial Auto
90 NC North Carolina Personal Auto Application
66 NC 8/97
64 NC
North Carolina Property Supplement - Prop Ins Notice
Disclosure
North Carolina Insurance Supplement - Consent to Obtain
Credit or Consumer Investigative Report
NCWCIP, Instructions for Completing ACORD 135 NC App136 NC
North Carolina Workers Comp Insurance Plan - Application135 NC
2008/04
65 NC
North Carolina Auto Supplement - Notice of Right to
Purchase Higher Limits of Uninsured Motorist (UM) and
Underinsured Motorist (UIM) Coverage
2010/02
2015/10
290 NC North Carolina Personal Automobile Application Section
67 NC 2012/03
North Carolina Insurance Supplement - Policy Service Fee
Schedule
2015/10
New York
New York Revocation of Executive Officers of an
Organization for Workers’ Compensation Coverage
174 NY 7/96
NYPIUA Application for Commercial Insurance2006/04177 NY
New York Election of Executive Officers of an Organization
for Workers’ Compensation Coverage
7/96173 NY
New York Garage and Dealers138 NY
New York Election of Partners or Self-Employed Persons for
Workers’ Compensation Coverage
172 NY 7/96
New York Notice of Election of a Corporation171 NY 10/96
New York Personal Auto Application90 NY
NYPIUA Instructions for Completing ACORD 177 NY70 NY 2006/04
New York Liability Supplement - "Claims-Made Policy"68 NY 2002/01
Instructions for Completion of ACORD 62 NY67 NY 2009/04
New York Commercial Auto137 NY
New York Application For Dwelling Insurance - NYPIUA62 NY 2009/04
New York Auto Supplement (Optional Basic Econ Loss)61 NY 3/94
2003/01 New York Auto Supplement - Spousal Liability Coverage65 NY
New York Auto Supplement - Supp UM/UIM Insurance
Coverage
64 NY 2008/06
New York Homeowners Supplement60 NY 2008/03
New York Personal Insurance Supplement - Notice of
Information Practices
38 NY 2005/04
New York Personal Property Supplement - Important Flood
Insurance Notice
69 NY 2008/08
New York Insurance Supplement39 NY 2011/03
New York Personal Auto Application Section290 NY
2012/01 New York Auto Supplement - Rental Reimbursement Notice66 NY
New Mexico Garage and Dealers138 NM
137 NM New Mexico Commercial Auto
New Mexico Personal Auto Application90 NM
New Mexico
2003/01 New Mexico Confidential Abuse Disclosure
New Mexico Executive Employee Affirmative Election Form
New Mexico Revocation
New Mexico Election to Accept
2004/10
173 NM
172 NM
171 NM
60 NM
2004/10
2004/10
2004/10
New Mexico Limited Liability Company Member Affirmative
Election Form
174 NM
2010/12
New Mexico Auto Supplement - UM Coverage Selection /
Rejection and Rejection of Stacked UM Coverage
61 NM
New Mexico Personal Auto Application Section290 NM
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
Ohio
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
171 OH Ohio FAIR Plan - Basic Property Application
170 OH
Ohio FAIR Plan - Instructions for Completion of Insurance
Apps
2002/09
90 OH Ohio Personal Auto Application
137 OH Ohio Commercial Auto
138 OH Ohio Garage and Dealers
Ohio Mine Subsidence Homeowners and Dwelling
Supplement
67 OH 2009/07
Ohio Offer of Mine Subsidence - Homeowners and Dwelling68 OH
2004/03
2009/07
Ohio Auto Supplement - Important Optional Disclosure Notice
Uninsured Motorist Property Damage Coverage
62 OH 2011/05
Ohio Personal Automobile Application Section290 OH
50 OK 2009/08 Oklahoma Owners Security Verification Form
Oklahoma
90 OK Oklahoma Personal Auto Application
51 OK Oklahoma Operators Security Verification Form
60 OK Oklahoma Auto Supplement - UM Coverage Law
137 OK
138 OK
Oklahoma Commercial Auto
Oklahoma Garage and Dealers
62 OK 2006/05
Oklahoma Property Supplement
Notice to Property Owners in Rural Fire Protection Districts
64 OK 2007/10 Oklahoma Liability Supplement
2009/08
2009/11
290 OK Oklahoma Personal Auto Application Section
Oregon
138 OR Oregon Garage and Dealers
38 OR
61 OR 2004/10
Oregon Notice of Information Practices (Privacy)
Oregon Auto Supplement - UM Coverage Selection
90 OR Oregon Personal Auto Application
137 OR Oregon Commercial Auto
62 OR 2006/01 Oregon Personal Lines Supplement
290 OR Oregon Personal Auto Application Section
2013/01
North Dakota
137 ND
138 ND
North Dakota Commercial Auto
North Dakota Garage and Dealers
68 ND 2004/07 North Dakota Supplement to Property Insurance - Fire District
90 ND North Dakota Personal Auto Application
38 ND 2005/08
North Dakota Personal Insurance Supplement - Notice of
Information Practices
50 ND 2007/08 North Dakota Insurance Identification Card
290 ND North Dakota Personal Auto Application Section
# Current Title Quantity Current Title QuantityFuture # Future
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
New York Construction Certificate of Liability Insurance
Addendum
855 NY 2014/05
2015/12
2015/12
2015/12
2015/12
62 ND 2015/04 North Dakota Insurance Supplement
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
ACORD Forms Index (rev. 09-30-2015)
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS - continued
South Carolina
South Carolina Personal Auto Application
South Carolina Auto Supplement - Offer of Opt UM/UIM
Coverage
61 SC
90 SC
2008/03
South Carolina Personal Property Supplement - Cancellation
Rules Disclosure
64 SC
2007/01 South Carolina Insurance Identification Card50 SC
2007/08
South Carolina Personal Automobile Application Section290 SC
South Carolina Garage and Dealers138 SC
South Carolina Commercial Auto137 SC
Pennsylvania
Pennsylvania Personal Auto Application90 PA
FAIR Plan Supplementary Questionnaire
Insurance Placement Facility of Pennsylvania
Basic Property Insurance Application
64 PA
2002/02 Pennsylvania Application for Executive Officer Exception171 PA
Pennsylvania UIM Coverage Select/Reject62 PA
Pennsylvania UM Coverage Select/Reject60 PA
Pennsylvania Financial Responsibility Card2007/0950 PA
2002/02 Pennsylvania Executive Officers Declaration172 PA
290 PA Pennsylvania Personal Auto Application Section
66 PA
Insurance Placement Facility of Pennsylvania
Dwelling Property 2 - Broad Form Application Supplement
2012/10
2012/10
Pennsylvania Auto Supplement - Important Notice61 PA 2014/02
Pennsylvania Commercial Auto137 PA
Pennsylvania Garage and Dealers138 PA
137 RI
138 RI
Rhode Island Commercial Auto
Rhode Island Garage and Dealers
65 RI 2003/04
Rhode Island Joint Reinsurance Association, Instructions for
Completing Homeowners Application ACORD 64 RI
Rhode Island Personal Auto Application90 RI
66 RI
Rhode Island Joint Underwriting Insurance
Application for Dwelling Fire and Personal Liability Insurance
Inspection and Placement
67 RI 2007/03
Rhode Island Joint Underwriting Insurance
Inspection Notice, Credit Reporting Notice and Instructions for
Completing Dwelling Fire and Personal Liability Application
ACORD 66 RI
68 RI 2003/04
Rhode Island Joint Underwriting Insurance
Application for Commercial Fire Insurance Inspection and
Placement
69 RI
Rhode Island Joint Underwriting Insurance
Inspection Notice, Credit Reporting Notice and Instructions for
Completing Commercial Fire Application ACORD 68 RI
2003/04
Rhode Island Personal Automobile Application Section290 RI
64 RI
Rhode Island Joint Reinsurance Association, Application for
Homeowners Insurance Inspection and Placement
Rhode Island
61 RI
Rhode Island Auto Supplement, Uninsured / Underinsured
Motorist Bodily Injury Coverage
2012/12
50 RI Rhode Island Insurance Identification Card2008/01
62 RI
Rhode Island Prop Suppl - Notice of Flood Coverage
Exclusion
2006/01
2012/07
2012/07
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
Puerto Rico
90 PR Puerto Rico Personal Auto Application
Texas
TX Personal Lines Supp. (Spanish Version) - Use of Credit
Information Disclosure
852 TX
Texas Garage and Dealers138 TX
TX Personal Lines Supp. - Use of Credit Information
Disclosure
851 TX
90 TX Texas Personal Auto Application
Texas Commercial Auto137 TX
Texas Liability Insurance Card50 TX
Texas Consumer Bill of Rights for Personal Auto60 TX 2013/01
Texas Homeowners and Personal Property - Rights67 TX
Texas Windstorm Insurance Association Application64 TX 2003/04
Texas Consumer Bill of Rights for Personal Auto (Spanish)62 TX
Texas Homeowners and Personal Property - Rights (Spanish)68 TX
Texas Special Mobile Home Windstorm/Haill Application69 TX 2000/08
2010/06
2010/06
Texas Personal Automobile Application Section290 TX
Texas Risk Pool Certificate of Property Coverage854 TX 2012/08
Texas Risk Pool Certificate of Liability Coverage855 TX 2015/02
2013/01
2013/01
2013/01
Tennessee
Tennessee Garage and Dealers138 TN
Tennessee Commercial Auto137 TN
Tennessee Personal Auto Application90 TN
Tennessee Insurance Identification Card50 TN 2007/02
Tennessee Personal Automobile Application Section290 TN
South Dakota Garage and Dealers138 SD
South Dakota Commercial Auto137 SD
South Dakota Personal Auto Application90 SD
South Dakota
50 SD 2007/02 South Dakota Insurance Identification Card
South Dakota Personal Auto Application Section290 SD
61 SD 2013/02 South Dakota Personal Umbrella Supplement
Puerto Rico Personal Auto Application Section290 PR
# Current Title Quantity Current Title QuantityFuture # Future
65
PA / DE
/ WV
2015/05
Texas Personal Property Supplement853 TX 2014/01
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
Page 9 of 12
2014/12
2015/05
2015/05
2015/05
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
ACORD Forms Index (rev. 09-30-2015)
Wyoming
90 WY Wyoming Personal Auto Application
137 WY Wyoming Commercial Auto
138 WY Wyoming Garage and Dealers
290 WY Wyoming Personal Auto Application Section
ACORD Forms Index
All packages contain 100 forms - Please specify number of packages required
STATE P&C FORMS - continued
Wisconsin
137 WI Wisconsin Commercial Auto
133 WI Wisconsin Workers Compensation Insurance Pool2010/04
134 WI Wisconsin Supplementary Non-Election Form8/99
135 WI Wisconsin Supplementary Election of Coverage Form8/99
136 WI
Wisconsin Supplement Limited Other States Coverage
Request
138 WI Wisconsin Garage and Dealers
177 WI
Wisconsin Automobile Insurance Plan Business Auto
Application
178 WI Wisconsin Automobile Insurance Plan - Truckers Application
2011/11
97 WI 2003/10
Wisconsin Automobile Insurance Plan
Private Passenger Auto Application
4 WI Wisconsin Employers First Report of Injury or Disease2003/04
90 WI Wisconsin Personal Auto Application
2011/11
2010/04
290 WI Wisconsin Personal Auto Application Section
Washington
137 WA Washington Commercial Auto
138 WA Washington Garage and Dealers
90 WA Washington Personal Auto Application
290 WA Washington Personal Auto Application Section
Virginia
62 VA 6/97
60 VA Virginia Auto Supplement - Rental Reimbursement Coverage8/94
Virginia Property Supplement
Ordinance or Law Coverage; Additional Cov Available
64 VA Virginia Property Supplement - Notice of Flood Insurance
67 VA 2000/11 Virginia Property Insurance Association
38 VA Virginia Notice of Information Practices (Privacy)
2005/01
2011/05
90 VA Virginia Personal Auto Application
137 VA Virginia Commercial Auto
138 VA Virginia Garage and Dealers
290 VA Virginia Personal Auto Application Section
West Virginia
West Virginia Personal Auto Application90 WV
West Virginia Commercial Auto137 WV
West Virginia Garage and Dealers138 WV
2005/07
West Virginia Property Supplement - Notice of Flood
Coverage Exclusion
862 WV
West Virginia Umbrella Liability Supplement
UM / UIM Coverage - Offer of Single Limits
68 WV
Illinois / Indiana / Kentucky / West Virginia Mine Subsidence
Property Insurance Supplement
67
West Virginia Personal and Commercial Umbrella Liability
Supplement - UM / UIM Coverage - Offer of Split Limits
2012/0466 WV
FAIR Plan Supplementary Questionnaire
West Virginia Essential Property Insurance Association
Basic Property Insurance Application
64 WV
West Virginia Auto Supplement - UM / UIM Coverage Offer
Single Limits
62 WV
West Virginia Auto Supplement - UM / UIM Coverage Offer
Split Limits
61 WV
West Virginia Umbrella Liability Supplement Important Notice65 WV
West Virginia Auto Supplement - UM / UIM Vehicle Coverage12/9360 WV
West Virginia Certificate of Insurance50 WV
West Virginia Personal Insurance Supplement
Notice of Insurance Information Practices
2006/0438 WV
2006/05
West Virginia Personal Auto Application Section290 WV
2012/04
2012/04
2012/04
10/9467 UT
Utah Auto Supplement
PIP Coverage, Loss of Income Waiver
6/9466 UT Utah Arbitration Provisions
Utah
Utah Commercial Auto137 UT
9/9363 UT Utah Fraud Statement
Utah Personal Auto Application90 UT
Utah Garage and Dealers138 UT
Utah Auto Supplement
Uninsured / Underinsured Motorist Coverage Selection
2013/0461 UT
Utah Personal Auto Application Section290 UT
United States
60 US 2015/01 Insurance Supplement - Offer of Terrorism Coverage
62 US
Insurance Supplement - Offer of Terrorism Coverage
Standard Fire Policy Only
64 US
Insurance Supplement - Offer of Terrorism Coverage
Workers Compensation
90 VI Virgin Islands Personal Auto Application
Virgin Islands
290 VI Virgin Islands Personal Auto Application Section
Vermont Garage and Dealers
Vermont Commercial Auto
138 VT
137 VT
Vermont
Vermont Personal Auto Application90 VT
2003/06 Vermont Insurance Supplement - Fair Credit Reporting Act66 VT
Vermont Automobile Insurance Identification Card50 VT 2007/02
Vermont Personal Auto Application Section290 VT
Page 10 of 12
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
# Current Title Quantity Current Title QuantityFuture # Future
65
PA / DE
/ WV
Future forms are intended for use on or after the first day of the edition date month. (e.g., edition date 2014/01 for use on or after 1/1/2014)
Utah Insurance Identification Card51 UT 2014/07
2014/01
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
2014/12
137 VI Virgin Islands Commercial Auto2014/08
2015/01
2015/01
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/05
2015/05
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
138 VI Virgin Islands Garage and Dealers2015/06
2015/07
2015/12
2015/12
2015/12
2015/12
2015/12
2015/12
2016/01
2016/01
2016/01
2016/01
2016/01
2016/01
ACORD Forms Index (rev. 09-30-2015)
ACORD Forms Index
Page 11 of 12
AUSTRALIA FORMS
TitleEditionNumber
3045 Interested Party Schedule
3101 Additional Remarks Schedule
3129 Commercial Motor Vehicle Schedule
3825 Professional Indemnity Insurance Application
3827 Business Package Application for Insurance
3826 Industrial Special Risks Insurance Application
TitleEditionNumber
3021 Private Motor Certificate of Currency
3022 Professional Indemnity Certificate of Currency
3023 Commercial Motor Certificate of Currency
3020 Home Certificate of Currency2012/02
3137 Commercial Motor Application for Insurance
3163 Commercial Driver Schedule
3823 Additional Situations Schedule
ACORD Australia Forms - Available ONLY on the ACORD Web Site
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600
2012/02
2012/02
2012/02
2012/02
2012/02
2012/02
2012/02
2012/02
2012/02
2012/02
2012/02
2012/10
3080 Home Application for Insurance2012/03
3090 Personal Motor Application for Insurance2012/03
3098 Personal Motor Vehicle Schedule2012/03
ACORD Forms Index (rev. 09-30-2015)
