Source: http://www.docstoc.com/docs/36360964/ACORD-Forms-Index-ACORD-Forms-Index
Timestamp: 2015-05-25 07:52:07
Document Index: 454511832

Matched Legal Cases: ['arts\n220', 'art)\n137', 'art)\n133', 'art)\n65', 'art 3', 'art 1', 'art 2', 'art 2', 'art 2', 'art 2', 'art 1', 'art 2', 'art 2', 'art 1', 'art 2', 'art 1', 'art 2', 'art 1', 'art 2', 'art 1', 'art 2', 'art 2', 'art 2', 'art 1', 'art 2', 'art 2', 'art 1', 'art 1', 'art 2', 'art 2']

ACORD Forms Index ACORD Forms Index by gabyion
36360964
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COUNTRYWIDE P&amp;C FORMS
Number      Edition   Title                                                          Quantity    Number    Edition   Title                                                              Quantity
1               2009/02   Property Loss Notice                                                      82         2007/06   Watercraft Application
2               2009/02   Automobile Loss Notice                                                    83         2008/11   Personal Umbrella Application Section
3               2009/02   General Liability Notice of Occur/Claim                                   88         2009/02   Personal Insurance Application - Applicant Information Section
4               2009/01   Workers Compensation - First Report of Injury or Illness                  89         2009/02   Residential Section
5               2009/05   Aircraft Loss Notice                                                      91         3/93a     Good Student Driver Training
6               2009/05   Aviation Witness / Passenger Schedule                                     92         2/95      Medical Statement
7               2009/05   Aviation Injured Schedule                                                 93         2004/10   Young Driver Questionnaire
11              2/95      Auto Accident Information Form                                            99         2009/02   Accidents / Convictions Schedule
12              2/95      Exchange of Information Form                                              101        2008/01   Additional Remarks Schedule
13              2/95      Witness Card                                                                                   Personal Auto Application Schedule - Additional Resident and
103        2008/01
20              2009/05   Certificate of Aviation Liability Insurance
125        2009/05   Commercial Insurance Application - Applicant Information Section
21              2009/05   Certificate of Aircraft Insurance
126        2007/05   Commercial General Liability Section
22              2007/02   Intermodal Interchange Certificate of Insurance
127        2009/01   Business Auto Section
23              2007/05   Automobile Certificate of Insurance
128        2008/05   Garage and Dealers Section
24              1/95      Certificate of Property Insurance
129        2009/01   Vehicle Schedule
25              2009/01   Certificate of Liability Insurance
130        2007/11   Workers Compensation Application
26              2002/01   Policy Certification Log
131        2009/02   Umbrella Section
27              2006/07   Evidence of Property Insurance
132        2008/09   Truckers / Motor Carriers Section
28              2006/07   Evidence of Commercial Property Insurance
133        2007/11   Workers Compensation Insurance Plan - Assigned Risk Section
35              1/97      Cancellation Request/Policy Release
139        2004/03   Statement/Schedule of Values
36              2007/01   Agent/Broker of Record Change
140        2007/09   Property Section
37              2008/01   Statement of No Loss
141 C      2007/06   Crime Section 2000
42              2009/07   Residential Property Replacement Cost
143        2004/01   Transportation Section
45              2009/04   Additional Interest Schedule
144        2007/07   Glass And Sign Supplement
50              2007/02   Automobile Insurance ID Card
145        2004/03   Accounts Receivable/Valuable Papers
50 WM           2007/03   Automobile Insurance ID Card (with Watermark)
146        2007/02   Equipment Floater Section
54              1/97      Financial Responsibility Form
147        2001/02   Installation/Builder&#39;s Risk Section
57              1/97      Financial Responsibility Form - Cancellation
148        2000/02   Electronic Data Processing Section
58              2007/11   Notice of Cancellation or Termination of Policy
149        2007/10   Dealers Section
60              2008/11   Flood Insurance Selection / Rejection
151        2008/01   Miscellaneous Crime Coverage Section
60 US           2008/02   Insurance Supplement - Notice - Offer of Terrorism Coverage
155 BM     2004/12   Boiler &amp; Machinery Section 2002
Insurance Supplement - Standard Fire Policy Only
62 US           2008/02                                                                             159        2004/03   Schedule of Insurance
Notice - Offer of Terrorism Coverage
63              2009/07   Fraud Statements                                                          160        2009/05   Business Owners Application
Insurance Supplement - Workers&#39; Compensation Only                         163        2000/11   Commercial Auto Driver Information Schedule
64 US           2008/02
175        2009/01   Commercial Policy Change Request
70              2009/06   Personal Policy Change Request (Except Auto)
180        1/97      Errors and Omissions Section - Electronic Data Processors, etc.
71              2009/06   Personal Auto Policy Change Request
185        2007/05   Restaurant/Tavern Supplement
72              2007/10   Certification of Mobile Home Tie-downs Supplement
186        2009/03   Contractors Supplement
73              2009/07   Solid Fuel Questionnaire
187        2003/07   Professional Liability Supplement
74              2008/07   Residence Based Business
188        2003/02   Employment Related Practices Liability Section
75              2007/01   Insurance Binder
190        2007/05   Supplemental Property Application
76              9/93      Binder Log
81              2005/08   Personal Inland Marine Application                                        193        2001/02   Open Cargo Section
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                       ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                          Page 1 of 10
COUNTRYWIDE P&amp;C FORMS - continued
Number   Edition   Title                                                             Quantity    Number   Edition   Title                                                            Quantity
194       2009/03   Truckers / Motor Carrier Supplement                                          815       2009/02   International Liability Exposure Supplement
195       10/96     Design Professional&#39;s Individual Property Survey                             816       2005/06   International Property Exposure Supplement
196       2008/03   Medical Professional Liability Insurance Application                         817       2007/08   P&amp;C Producer Appointment Form - Appointment Section
199       1/99      Application Supplement - Undertaking                                         818       2007/08   P&amp;C Producer Appointment Form - Background Questions
200       3/93      Producer Account                                                                                 P&amp;C Producer Appointment Form - Additional Appointment or
819       2007/08
201       3/93      Producer Account Discrepancy Notice
822       2009/07   Driver Work / School Address Information Supplement
210       2001/05   Yacht Section
823       2009/09   Additional Premises Information Schedule
225       1/98      Policyholder&#39;s Report
Professional / Specialty Insurance Application - For Use in
226       3/93      Statement of Premium Adjustment                                              825       2008/01
Management, Executive &amp; Professional Lines - Applicant Section
275       2009/05   Aviation Insurance Binder                                                    827       2008/01   Employment Practices Liability Insurance Section
276       2009/05   Aircraft Insurance Binder                                                    828       2008/07   Fiduciary Liability Coverage Section
301       2008/06   National Flood Insurance Program - Flood Insurance Application               829       2009/05   Forms and Endorsements Schedule
302       2008/06   NFIP - Flood Insurance General Change Endorsement                            830       2008/11   Property Insurance Card
303       2008/06   NFIP - Flood Insurance Preferred Risk Policy Application
304       2008/06   NFIP - Flood Insurance Cancellation / Nullification
325       2009/06   Aviation Insurance Application - Applicant Information Section
326       2006/04   Airport Property Supplement
327       2006/04   Airport and FBO Liability Section
328       2006/04   Private Hangar Liability Section
329       2009/06   Aviation Products Liability
330       2009/04   Aircraft Section
331       2006/06   Pilot Experience
332       2006/04   Hangar Schedule
333       2009/05   Aircraft Schedule
335       2009/06   Aviation Policy Change Request – Applicant Information Section
336       2009/06   Airport Property Change Request
337       2009/06   Airport and FBO Liability Change Request
338       2009/06   Private Hangar Liability Change Request
339       2009/06   Aviation Products Liability Change Request
340       2009/06   Aircraft Change Request
341       2009/06   Pilot Experience Change Request
342       2009/06   Hangar Change Request
350 WM    2009/06   Watermark Paper - 20 # ID Card Stock (4-part perforation)
360 WM    2009/06   Watermark Paper - 32 # ID Card Stock (4-part perforation)
370 WM              Watermark Paper - 32 # ID Card Stock (non-perforated)
401       2007/09   Agriculture Application
402       2009/03   Agriculture Property Section
403       2007/09   Agriculture Prop Sect - Scheduled/Unscheduled Personal Property
404       2007/09   Agriculture Liability Section
405       2007/09   Agriculture Premises Diagram
Agriculture Supplement - Unscheduled Farm Personal Property
406       2007/09
407       2007/09   Livestock Mortality Section
408       2007/09   Equine Liability Supplement
410       2004/04   Small Farm/Ranch Application
501       2004/07   Surety Report of Execution
610       2009/04   Premium Payment Supplement
801       2002/01   Railroad Protective Liability Supplement
802       2007/07   Hotel/Motel Supplement
807       2009/02   Directors &amp; Officers Liability Section
808       2009/03   P&amp;C Agency Appointment Form
Business Income / Extra Expense / Rental Value
810       2007/07
Supplement to Property Section
811       2007/07   Value Reporting Information Supplement to Property Section
812       2006/02   Agency Questionnaire
813       2005/03   Request for Proof of Property Insurance
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                  ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 2 of 10
STATE P&amp;C FORMS
Number   Edition   Title                                                                Quantity    Number    Edition   Title                                                                 Quantity
Alabama                                                                                             Colorado
50 AL     2007/10   Alabama Insurance Identification Card                                           50 CO      2007/03   Colorado Insurance Identification Card
62 AL     5/98      Alabama Insurance Application Supplement                                        61 CO      2009/02   Colorado Auto Supplement - Summary of Coverages
90 AL     2004/04   Alabama Personal Automobile Application                                         62 CO      2/97      Colorado Personal Property Supplement - Coverage Disclosure
137 AL    2004/04   Alabama Commercial Auto                                                                              Colorado Auto Supplement - Colorado Offer of Medical Payments
64 CO      2009/01
138 AL    2004/04   Alabama Garage and Dealers
90 CO      2009/01   Colorado Personal Automobile Application Section
137 CO     2008/01   Colorado Commercial Auto
61 AK     7/97      Alaska Auto Supplement - UM/UIM Coverage Selection
138 CO     2008/01   Colorado Garage and Dealers
62 AK     2/98      Alaska Auto Supplement - Exclusion of Named Drivers
171 CO     2006/01   Colorado Rejection of Coverage by Corporate Officers
90 AK     2005/08   Alaska Personal Auto Application
137 AK    2005/08   Alaska Commercial Auto
Notice of Information Practices (Privacy) for states
138 AK    2005/08   Alaska Garage and Dealers                                                       38         2008/04
of CA / CT / GA / IL / NV / NJ / RI / VA / WA
171 AK    6/98      Alaska Petition For Executive Officer Waiver                                    50 CT      2009/01   Connecticut Insurance Identification Card
Arkansas                                                   61 CT      2004/11   Connecticut Auto Supplement - UM Coverage
50 AR     2007/10   Arkansas Proof of Insurance Card                                                66 CT      2006/06   Connecticut FAIR Plan Application for Property/Liability Insurance
61 AR     2002/03   Arkansas Auto Supplement UM/UIM Coverage                                        90 CT      2005/11   Connecticut Personal Automobile Application
Arkansas Property Supplement - Declination of                                   137 CT     2005/11   Connecticut Commercial Auto
67 AR     2000/02
138 CT     2005/11   Connecticut Garage and Dealers
90 AR     2008/04   Arkansas Personal Auto Application Section
171 CT     2006/08   Connecticut Workers&#39; Comp. Comm. - Coverage Election by
137 AR    2004/05   Arkansas Commercial Auto                                                                             Employee Who Is an Officer of a Corporation, Manager of an
LLC, or Member of a Multiple-Member LLC
138 AR    2000/10   Arkansas Garage and Dealers
172 CT     2006/08   Connecticut Workers&#39; Comp. Comm. - Coverage Election by
Arizona                                                                        Employees who are Members of a Partnership
38 AZ     2003/10   Arizona Notice of Information Practices (Privacy)                                                    Connecticut Workers&#39; Comp. Comm. - Coverage Election by Sole
173 CT     2006/08
Proprietor or Single-Member LLC
50 AZ     2007/11   Arizona Insurance Identification Card
61 AZ     2001/02   Arizona Auto Supplement UM/UIM Coverage Selection
Delaware Personal Insurance Supplement
90 AZ     2006/04   Arizona Personal Automobile Application                                         38 DE      2008/04
137 AZ    2006/04   Arizona Commercial Auto                                                         50 WM      2007/03   Automobile Insurance ID Card (with Watermark)
138 AZ    2006/04   Arizona Garage and Dealers                                                                           DE Auto Supplement, DE Motorist&#39;s Protection Act - Required
61 DE      2006/10
62 DE      2004/10   DE Auto Supplement, PIP Deductible Options
38        2008/04                                                                                                        Insurance Placement Facility of Delaware
of CA / CT / GA / IL / NV / NJ / RI / VA / WA                                   64 DE      2006/08
Basic Property Insurance Application
50 CA     2004/07   California Insurance Identification Card
51 CA     2004/07   California Evidence of Liability Insurance                                                 2006/08   FAIR Plan Supplementary Questionnaire
52 CA     2007/07   California Fleet Auto Insurance Identification Card                             90 DE      2008/04   Delaware Personal Auto Application Section
California Auto Supplement - Mandatory UM Bodily Injury /                       137 DE     2006/07   Delaware Commercial Auto
61 CA     2008/03
Property Damage Coverage Offer
138 DE     2006/07   Delaware Garage and Dealers
64 CA     2004/02   California Insurance Supplement - Agency Language
171 DE     2006/01   Delaware Executive Officer(s) Exclusion
65 CA     2004/07   California Insurance Supplement - Race, National Origin, Gender
66 CA     2/98      California Offer of Earthquake Coverage
Application to District of Columbia Property Insurance Facility for
67 CA     2005/03   California Residential Property Insurance Disclosure                            64 DC      2009/06
California Scheduled Personal Property Loss Computation                                              District of Columbia Property Insurance Facility - Essential
68 CA     2001/03                                                                                   66 DC      2005/12
Disclosure                                                                                           Homeowners Insurance Inspection and Placement Application p. 1
90 CA     2007/04   California Personal Auto Application                                                                 District of Columbia Property Insurance Facility - Essential
67 DC      2005/12
Homeowners Insurance Inspection and Placement Application p. 2
137 CA    2007/01   California Commercial Auto
90 DC      2006/04   District of Columbia Personal Auto Application
138 CA    2007/01   California Garage and Dealers
137 DC     2007/07   District of Columbia Commercial Auto
177 CA    2001/03   California Auto Body Repair Consumer Bill of Rights
138 DC     2006/04   District of Columbia Garage and Dealers
California FAIR Plan Property Insurance - Application for Property
855 CA    2008/06
California FAIR Plan Property Insurance - Business Owners
856 CA    2004/07
California Earthquake Authority - Application for Earthquake
857 CA    2009/05
860 CA    2004/12   California Auto Supplement - Driver Self Certification
861 CA    2006/07   California Residential Property Insurance Bill of Rights
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                      ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                         Page 3 of 10
STATE P&amp;C FORMS - continued
Number   Edition   Title                                                              Quantity    Number   Edition   Title                                                                  Quantity
Florida                                                                                           Illinois
50 FL     2009/07   Florida Personal Auto ID Card (two part)                                                          Notice of Information Practices (Privacy) for states
38        2008/04
51 FL     2009/07   Florida Commercial Auto ID Card
50 IL     2007/03   Illinois Insurance Identification Card
61 FL     2008/06   Florida Auto Supplement - Rejection/Election of UM Coverage
61 IL     2003/03   Illinois Auto Supplement - UM/UIM
62 FL     2008/06   Florida Auto Supplement - Personal Injury Protection Options
Illinois Property Supplement - Notice of Availability of
Florida Auto Supplement - Notice to Policyholders - Florida                   62 IL     2007/08
64 FL     2008/06                                                                                                     Earthquake Insurance
Notification of Availability of Uninsured Motorist Coverage
Mine Subsidence Property Insurance Supplement
65 FL     2007/08   Florida Residential Property Supplement                                       67        2008/04
Illinois, Indiana, Kentucky, West Virginia
Florida Insurance Supplement                                                  69 IL     2007/02   Illinois FAIR Plan - App for Homeowners &amp; Dwelling Property
66 FL     2001/08
Credit Report Disclosure Information
90 IL     2003/10   Illinois Personal Auto Application
67 FL     7/94      Florida Homeowners Supplement
137 IL    2003/03   Illinois Commercial Auto
68 FL     2004/09                                                                                 138 IL    2003/03   Illinois Garage and Dealers
Residential - Dwelling Wind Only
Citizens Property Insurance Corporation                                       171 IL    2005/06   Illinois FAIR Plan Application for Commercial Property Insurance
69 FL     2004/09
Wind Only Supplemental Residential - Application Schedule
90 FL     2008/05   Florida Personal Auto Application
50 IN     2007/11   Indiana Insurance Identification Card
130 FL    2002/07   Florida Workers Compensation Application
133 FL    2007/07   Florida Workers Comp. Addendum to ACORD 130 FL                                67        2008/04
Florida Workers Comp. Instructions for                                        90 IN     2009/09   Indiana Personal Auto Application
134 FL    2009/07
Completing ACORD 130 FL and 133 FL
137 IN    2009/09   Indiana Commercial Auto
137 FL    2009/08   Florida Commercial Auto
138 IN    2009/09   Indiana Garage and Dealers
138 FL    2009/08   Florida Garage and Dealers
171 FL    2004/04   Florida Notice of Election of Coverage
50 IA     2007/08   Iowa Financial Responsibility Card
172 FL    2007/08   Florida Revocation of Election to be Exempt
61 IA     2002/02   Iowa Auto Supplement - UM/UIM Offer/Rejection
173 FL    2007/08   Florida Notice of Election to be Exempt
62 IA     2/98      Iowa Auto Supplement - Notice Regarding UM/UIM Coverage
174 FL    2007/08   Florida Revocation of Election of Coverage
64 IA     4/98      Iowa Auto Supplement - UM/UIM Stacking Coverage Notice
175 FL    3/97      Florida Workers Compensation Monthly Change Sheet
65 IA     2008/01   Iowa Auto Supplement - Aftermarket Crash Parts
220 FL    2003/08                                                                                                     Iowa Personal Insurance Supplement
Commercial and Commercial - Residential Wind Only                             66 IA     2006/07
Disclosure Use of Claims History
Citizens Property Ins Corp, Wind Only - Supplemental Application
221 FL    2002/07                                                                                 90 IA     2006/07   Iowa Personal Auto Application
Schedule Commercial and Commercial - Residential
Georgia                                                 137 IA    2007/01   Iowa Commercial Auto
Notice of Information Practices (Privacy) for states                          138 IA    2007/01   Iowa Garage and Dealers
50 GA     2008/11   Georgia Insurance Policy Information Card
Kansas Personal Insurance Supplement - Notice of Insurance
51 GA     2004/07   Georgia Fleet Policy Information Card                                         38 KS     2005/03
Georgia Auto Supplement - Georgia Auto Disclosure Form,                       90 KS     2008/06   Kansas Personal Auto Application
64 GA     2009/01
Notice to Policyholders, Uninsured Motorist Coverage Selection
137 KS    2008/07   Kansas Commercial Auto
90 GA     2009/01   Georgia Personal Automobile Application Section
138 KS    2008/07   Kansas Garage and Dealers
137 GA    2009/02   Georgia Commercial Auto
171 KS    2005/11   Kansas Elec. of Individual, Partner or Self-Employed Individual
138 GA    2006/11   Georgia Garage and Dealers
172 KS    2005/11   Kansas Cancel. of Elec. of Individual, Partner or Self-Employed Ind.
171 GA    2001/03   Georgia Workers&#39; Comp - Corporate Officer Rejection
173 KS    2005/11   Kansas Cancellation of Election Not to Accept Coverage
174 KS    2005/11   Kansas Election Not to Accept Coverage
50 HI     2008/01   Hawaii Auto ID Card
176 KS    2005/11   Kansas Election of Employer to Cover Employees
60 HI     2005/01   Hawaii Auto Supplement - UM/UIM/PIP
177 KS    2005/11   Kansas Election of Coverage for Volunteer Workers
90 HI     2005/01   Hawaii Personal Automobile Application
178 KS    2005/11   Kansas Cancellation of Election of Employer to Cover Employees
94 HI     2001/03   Hawaii Vehicle Inspection Report Supplement
179 KS    2005/11   Kansas Cancel. of Election of Coverage for Volunteer Workers
137 HI    2005/01   Hawaii Commercial Auto
180 KS    2005/11   Kansas Election of Coverage for Persons Performing Public Service
138 HI    2005/01   Hawaii Garage and Dealers
Kansas Cancellation of Election of Coverage for Persons
181 KS    2005/11
Idaho                                                                     Performing Public Service
50 ID     2007/10   State of Idaho Liability Insurance Identification Card                        182 KS    2001/05   Kansas Election of a Noncompensated Volunteer to be Covered
Idaho Auto Supplement - Idaho Uninsured Motorist and                                              Kansas Cancellation of Election of a Noncompensated Volunteer
61 ID     2009/01                                                                                 183 KS    2001/05
Underinsured Motorist Disclosure Statement                                                        to be Covered
90 ID     2009/01   Idaho Personal Automobile Application Section
137 ID    2009/01   Idaho Commercial Auto
138 ID    2009/01   Idaho Garage and Dealers
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                    ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                       Page 4 of 10
Number       Edition   Title                                                              Quantity    Number       Edition   Title                                                               Quantity
Kentucky                                                                                  Massachusetts (continued)
50 KY         2006/01   Commonwealth of Kentucky Proof of Insurance (2 part)                                                  Massachusetts Property Insurance Underwriting Association -
66 MA         2005/01   Inspection Notice, Credit Reporting Notice and Instructions for
64 KY         2009/01   Kentucky FAIR Plan Homeowners Application                                                             Completing Dwelling Fire Application ACORD 65 MA
65 KY         2009/01   Kentucky FAIR Plan Dwelling Fire Application                                  90 MA         2008/03   Application for Massachusetts Motor Vehicle Insurance
66 KY         2009/01   Kentucky FAIR Plan Farm Fire Application                                      95 MA         2007/08   Massachusetts Renewal Application (Statement of Facts)
Mine Subsidence Property Insurance Supplement                                 137 MA        2006/05   Massachusetts Commercial Auto
67            2008/04
138 MA        2006/05    Massachusetts Garage and Dealers
68 KY         2009/01   Kentucky FAIR Plan Commercial Fire Application
69 KY         2009/01   Kentucky FAIR Plan Woodstove Questionnaire
50 MI         2007/12   Michigan Insurance Auto ID Card
90 KY         2006/04   Kentucky Personal Automobile Application
50 MI (set)   2007/12   Michigan Insurance Auto ID Card (2 part)
137 KY        2006/04   Kentucky Commercial Auto
62 MI         2000/01   Michigan Collision Insurance Options Notice
138 KY        2000/09   Kentucky Garage and Dealers
64 MI         2000/10   Michigan Basic Property Insurance Assn Insurance Application
90 MI         2009/01   Michigan Personal Automobile Application Section
50 LA         2008/03   Louisiana Auto ID Card (2 part)
133 MI        2009/02   Michigan Application for Workers&#39; Compensation Insurance
60 LA         4/98      Louisiana Dwelling Supplement - Loss Settlement DWG1
137 MI        2000/09   Michigan Commercial Auto
61 LA         2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO4)
138 MI        4/96      Michigan Garage and Dealers
62 LA         4/98      Louisiana Commercial Property Supplement
Michigan Automobile Insurance Placement Facility Supplement to
64 LA         2001/05   Louisiana Homeowners Supplement - Loss Settlement (HO2 &amp; 3)                   139 MI        2004/07   ACORD App. - Application for Commercial, Public Automobiles
and Corporately Owned Vehicles
65 LA         2001/02   Louisiana Homeowners Supplement - Loss Settlement (HO6)
171 MI        2005/01   Michigan Notice of Election
66 LA         4/98      Louisiana Dwelling Supplement - Loss Settlement DWG2 &amp; 3
172 MI        4/96      Michigan App for Exclusion of Partner(s), Spouse, Child or Parent
67 LA         5/98      Louisiana Certification of Mobile Home Tie Downs
173 MI        2000/09   Michigan WC Placement Facility Specific Person Exclusion
68 LA         4/98      Louisiana Plan Services Application for Insurance
90 LA         2009/01   Louisiana Personal Auto Application
38 MN         2005/08   Minnesota Notice of Information Practices (Privacy)
137 LA        2009/01   Louisiana Commercial Auto
62 MN         2000/01   Minnesota Auto Supplement
138 LA        2009/01   Louisiana Garage and Dealers
65 MN         2005/06   Minnesota Guaranty Association Notice
861 LA        2005/07   Louisiana Auto Supplement - Active Military Personnel Affidavit
90 MN         2006/08   Minnesota Personal Automobile Application
862 LA        2009/06   Louisiana Property Supplement - Hurricane Loss Mitigation Survey
137 MN        2006/08   Minnesota Commercial Auto
138 MN        2006/08   Minnesota Garage and Dealers
50 ME         2007/08   Maine Motor Vehicle Insurance Identification Card
90 ME         2005/08   Maine Personal Auto Application
50 MS         2008/01   Mississippi Auto Insurance ID Card
137 ME        2000/09   Maine Commercial Auto
61 MS         2006/01   Mississippi Auto Supplement - Non-Stacking UM Insurance
138 ME        2000/09   Maine Garage and Dealers
90 MS         2004/09   Mississippi Personal Auto Application
137 MS        2004/09   Mississippi Commercial Auto
39 MD         2003/05   Maryland Application Supp Notice of Intent to Use Credit History
138 MS        2004/09   Mississippi Garage and Dealers
62 MD         1/98      Maryland Commercial Auto Supplement
139 MS        2/99      Mississippi Statement/Schedule of Values
Maryland Property Insurance Availability Program
64 MD (set)   2007/01
Essential Property Insurance Inspection and Placement (4 part)                                                             Missouri
Maryland Property Insurance Availability Program - Essential                  50 MO (set)   2007/05   Missouri Auto Insurance ID Card (2 part)
65 MD         2005/12   Homeowners Insurance Inspection and Placement (p.1 of 2)
Missouri Property Supplement - Notice of Availability of
Maryland Property Insurance Availability Program - Essential                  62 MO         2007/08
66 MD         2005/12                                                                                                         Earthquake Insurance
Homeowners Insurance Inspection and Placement (p.2 of 2)
67 MO         2009/06   Missouri FAIR Plan Insurance Application
Maryland Personal Auto Supplement - Mandatory Offer of
67 MD         2005/01   Increased Liability Coverage for Claims of Family Members,                    90 MO         2008/08   Missouri Personal Auto Application
Mandatory PIP Waiver, and Mandatory UM Coverage Waiver
137 MO        2008/08   Missouri Commercial Auto
Maryland Personal Property Supplement - Statement Regarding
68 MD         2006/10                                                                                 138 MO        2008/08   Missouri Garage and Dealers
69 MD         2007/01   Maryland Insurance Supplement - Notice of Underwriting Period
90 MD         2009/01   Maryland Personal Auto Application Section
137 MD        2009/01   Maryland Commercial Auto
138 MD        2009/01   Maryland Garage and Dealers
Maryland Personal Property Supplement - Loss from Water and
851 MD        2008/11
60 MA         2001/05
Application for Homeowners Insurance
61 MA         2001/05
Instructions to Complete Homeowners Application ACORD 60 MA
Massachusetts Residential Property Liability Supplement
64 MA         2/97
Lead Poisoning Liability Disclosure Notice
Massachusetts Property Insurance Underwriting Association -
65 MA         2005/01
Application for Dwelling Fire Insurance Inspection and Placement
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                           ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                              Page 5 of 10
Number   Edition   Title                                                            Quantity    Number   Edition   Title                                                              Quantity
Montana                                                                                      New Mexico
60 MT     2003/09   Montana Application Supplement - Refusal to Renew                           60 NM     2003/01   New Mexico Confidential Abuse Disclosure
90 MT     2009/08   Montana Personal Auto Application                                                               New Mexico Auto Supplement - UM Coverage Selection/Rejection
61 NM     2005/04
and Rejection Of Stacked UM Coverage
133 MT    8/98                                                                                  90 NM     2006/02   New Mexico Personal Auto Application
Worker’s Compensation Application Supplement
137 MT    2009/08   Montana Commercial Auto                                                     137 NM    2005/04   New Mexico Commercial Auto
138 MT    2009/08   Montana Garage and Dealers                                                  138 NM    2005/01   New Mexico Garage and Dealers
Nebraska                                               171 NM    2004/10   New Mexico Executive Employee Affirmative Election Form
50 NE     2007/01   Nebraska Auto Liability Insurance Identification Card                       172 NM    2004/10   New Mexico Election to Accept
90 NE     2003/12   Nebraska Personal Auto Application                                          173 NM    2004/10   New Mexico Revocation
137 NE    2001/10   Nebraska Commercial Auto                                                    174 NM    2004/10   NM Limited Liability Company Member Affirmative Election Form
138 NE    8/97      Nebraska Garage and Dealers                                                                                         New York
Nevada                                                38 NY     2005/04
New York Personal Insurance Supplement - Notice of Information
38        2008/04                                                                               60 NY     2008/03   New York Homeowners Supplement
51 NV     2008/11   Nevada Temporary Insurance Identification Card                              61 NY     3/94      New York Auto Supplement (Optional Basic Econ Loss)
Nevada Auto Supplement, Mandatory Offer of Medical Payments                 62 NY     2009/04   New York Application For Dwelling Insurance - NYPIUA
61 NV     2002/12
Coverage and Uninsured Motorists Coverage
64 NY     2008/06   New York Auto Supplement - Supp UM/UIM Insurance Coverage
62 NV     2001/05   Nevada Umbrella Supplement
65 NY     2003/01   New York Auto Supplement - Spousal Liability Coverage
90 NV     2001/03   Nevada Personal Auto Application
67 NY     2009/04   Instructions for Completion of ACORD 62 NY
137 NV    2001/11   Nevada Commercial Auto
68 NY     2002/01   New York Liability Supplement - &quot;Claims-Made Policy&quot;
138 NV    3/96      Nevada Garage and Dealers
New York Personal Property Supplement - Important Flood
69 NY     2008/08
New Hampshire                                                                   Insurance Notice
90 NH     2006/05   New Hampshire Personal Auto Application                                     70 NY     2006/04   NYPIUA Instructions for Completing ACORD 177 NY
137 NH    2006/05   New Hampshire Commercial Auto                                               90 NY     2005/04   New York Personal Auto Application
138 NH    2006/05   New Hampshire Garage and Dealers                                            137 NY    2003/11   New York Commercial Auto
New Jersey                                                138 NY    2003/11   New York Garage and Dealers
Notice of Information Practices (Privacy) for states                        171 NY    10/96     New York Notice of Election of a Corporation
New York Election of Partners or Self-Employed Persons for
50 NJ     2005/05   Temporary State of New Jersey Insurance Identification Card                 172 NY    7/96
50 WM     2007/03   Automobile Insurance ID Card (with Watermark)                                                   New York Election of Executive Officers of an Organization for
173 NY    7/96
51 NJ     2007/06   Permanent State of New Jersey Insurance Identification Card
New York Revocation of Executive Officers of an Organization for
60 NJ     2001/10   New Jersey Homeowners Insurance Supplement Flood Exclusion                  174 NY    7/96
61 NJ     2009/09   New Jersey Auto Insurance Buyer&#39;s Guide                                     177 NY    2006/04   NYPIUA Application for Commercial Insurance
62 NJ     2006/10   New Jersey Auto Supplement - Basic Policy Coverage                                                              North Carolina
64 NJ     2006/10   New Jersey Auto Supplement - Standard Policy Coverage                       62 NC     9/97      North Carolina JUA/IUA FAIR and Beach Plan Coverage Instruc.
65 NJ     2003/02   New Jersey Property Insurance Supplement - Earthquake                       64 NC     2008/04   North Carolina Property Supplement - Prop Ins Notice Disclosure
67 NJ     2008/07   NJUIA Dwelling Fire Application                                                                 North Carolina Auto Supplement - Notice of Right to Purchase
65 NC     2009/01   Higher Limits of Uninsured Motorist (UM) and Underinsured
68 NJ     2003/07   NJUIA Commercial Fire Application                                                               Motorist (UIM) Coverage
90 NJ     2000/09   New Jersey Personal Automobile Application                                                      North Carolina Insurance Supplement - Consent to Obtain Credit
66 NC     8/97
or Consumer Investigative Report
94 NJ     2006/04   Insurance Inspection Report
90 NC     2009/04   North Carolina Personal Automobile Application Section
132 NJ    2006/07                                                                               135 NC    2009/08   North Carolina Workers Compensation Application
133 NJ    2008/09   New Jersey Workers Compensation Insurance Application                       136 NC    2007/10   NCWCIP, Instructions for Completing ACORD 135 NC App
New Jersey Workers Compensation Insurance Plan                              137 NC    2007/06   North Carolina Commercial Auto
134 NJ    2007/01
Notice of Election - Proprietors and Partners
138 NC    2007/06   North Carolina Garage and Dealers
135 NJ    2009/09
Supplemental Employee Leasing Application                                                                        North Dakota
New Jersey Workers Compensation Insurance Plan                                                  North Dakota Personal Insurance Supplement - Notice of
136 NJ    2009/09                                                                               38 ND     2005/08
Truckers Supplemental Application                                                               Information Practices
137 NJ    2008/08   New Jersey Commercial Auto                                                  50 ND     2007/08   North Dakota Insurance Identification Card
138 NJ    2009/04   New Jersey Garage and Dealers                                               68 ND     2004/07   North Dakota Supplement to Property Insurance - Fire District
New Jersey Workers Compensation Insurance Plan - NJ Workers                 90 ND     2005/08   North Dakota Personal Auto Application
171 NJ    2003/07
Compensation and Employers Liability Manual Part 3, Section 14
137 ND    2002/02   North Dakota Commercial Auto
138 ND    2000/07   North Dakota Garage and Dealers
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                   Page 6 of 10
Number    Edition   Title                                                              Quantity    Number   Edition   Title                                                               Quantity
Ohio                                                                                        Rhode Island
67 OH      2009/07   Ohio Mine Subsidence Homeowners and Dwelling Supplement                                           Notice of Information Practices (Privacy) for states
68 OH      2009/07   Ohio Offer of Mine Subsidence - Homeowners and Dwelling
50 RI     2007/09   Rhode Island Insurance Identification Card
90 OH      2003/09   Ohio Personal Auto Application
61 RI     4/95      Rhode Island Auto Supplement, UM BI Coverage Notice
137 OH     2002/11   Ohio Commercial Auto
62 RI     2006/01   Rhode Island Prop Suppl - Notice of Flood Coverage Exclusion
138 OH     2002/11   Ohio Garage and Dealers
170 OH     2002/09   Ohio FAIR Plan - Instructions for Completion of Insurance Apps                64 RI     2001/05
Application for Homeowners Insurance Inspection and Placement
171 OH     2004/03   Ohio FAIR Plan - Basic Property Application                                                       Rhode Island Joint Reinsurance Association
65 RI     2001/05
Instructions for Completing Homeowners Application ACORD 64 RI
172 OH     2002/09   Ohio FAIR Plan - Homeowners Supplement
Rhode Island Joint Underwriting Insurance
173 OH     2002/09   Ohio FAIR Plan - Dwelling Fire Supplement                                     66 RI     2007/03   Application for Dwelling Fire and Personal Liability Insurance
174 OH     2002/09   Ohio FAIR Plan - Commercial Supplement
175 OH     2002/09   Ohio FAIR Plan - Farm Supplement                                              67 RI     2007/03   Inspection Notice, Credit Reporting Notice and Instructions for
Completing Dwelling Fire and Personal Liability Application ACORD
176 OH     2002/09   Ohio FAIR Plan - Rehabilitation Supplement                                                        66 RI
177 OH     2002/09   Ohio FAIR Plan - Bowling Alley Supplement                                     90 RI     2009/01   Rhode Island Personal Automobile Application Section
Oklahoma                                                  137 RI    2003/05   Rhode Island Commercial Auto
50 OK      2009/08   Oklahoma Owners Security Verification Form                                    138 RI    2003/05   Rhode Island Garage and Dealers
51 OK      2009/08   Oklahoma Operators Security Verification Form                                                                      South Carolina
60 OK      2009/11   Oklahoma Auto Supplement - UM Coverage Law                                    50 SC     2007/01   South Carolina Insurance Identification Card
61 OK      3/94      Oklahoma Auto Supplement - Election of Non-Stacked Coverage                   61 SC     2007/08   South Carolina Auto Supplement - Offer of Opt UM/UIM Coverage
Oklahoma Property Supplement                                                  62 SC     2/96      South Carolina Commercial Auto Supplement - Affidavit
62 OK      2006/05
Notice to Property Owners in Rural Fire Protection Districts
South Carolina Personal Property Supplement - Cancellation Rules
63 OK      10/97     Oklahoma Fraud Statement                                                      64 SC     2008/03
64 OK      2007/10   Oklahoma Liability Supplement                                                 71 SC     2003/03   AIP of South Carolina - Private Passenger Policy Change Request
90 OK      2003/12   Oklahoma Personal Auto Application                                            90 SC     2007/08   South Carolina Personal Automobile Application
137 OK     2001/11   Oklahoma Commercial Auto                                                      97 SC     2007/01   AIP of South Carolina - Private Passenger Application
138 OK     3/96      Oklahoma Garage and Dealers                                                   129 SC    2007/01   AIP of South Carolina - Vehicle Schedule
Oregon                                                  137 SC    2007/08   South Carolina Commercial Application
38 OR      2003/05   Oregon Notice of Information Practices (Privacy)                              138 SC    2007/08   South Carolina Garage and Dealers
61 OR      2004/10   Oregon Auto Supplement - UM Coverage Selection                                175 SC    2009/04   AIP of South Carolina - Commercial Auto Policy Change Request
90 OR      2009/07   Oregon Personal Auto Application                                              177 SC    2009/04   AIP of South Carolina - Commercial Application
137 OR     2009/08   Oregon Commercial Auto                                                        179 SC    2009/04   AIP of South Carolina - Garage Application
138 OR     2009/08   Oregon Garage and Dealers                                                     181 SC    2003/03   AIP of South Carolina - Company Performance Complaint Form
Pennsylvania                                                 182 SC    2003/03   AIP of South Carolina - Producer Performance Complaint Form
50 PA      2007/09   Pennsylvania Financial Responsibility Card                                    183 SC    2003/03   AIP of South Carolina - Automobile Loss Notice
60 PA      2008/01   Pennsylvania UM Coverage Select/Reject                                        184 SC    2004/06   AIP of South Carolina - Garage Supplemental Form
61 PA      2007/08   Pennsylvania Auto Supplement - First Party Benefits Coverage                  185 SC    2007/11   AIP of South Carolina - UM/UIM for Private Passenger Risks
62 PA      2008/01   Pennsylvania UIM Coverage Select/Reject                                       186 SC    2007/11   AIP of South Carolina - UM/UIM for Commercial Risks
Insurance Placement Facility of Pennsylvania                                  187 SC    2003/03   AIP of South Carolina - Name and/or Ownership Change
64 PA      2006/08
AIP of South Carolina - Endorsement Voiding Auto Insurance
65                                                                                                 188 SC    2003/03
2006/08   FAIR Plan Supplementary Questionnaire                                                             While Named Person is Operating Car
AIP of South Carolina - Electronic Application Submission
90 PA      2009/07   Pennsylvania Personal Auto Application Section                                851 SC    2003/03
137 PA     2009/07   Pennsylvania Commercial Auto                                                                                        South Dakota
138 PA     2009/07   Pennsylvania Garage and Dealers                                               50 SD     2007/02   South Dakota Insurance Identification Card
171 PA     2002/02   Pennsylvania Application for Executive Officer Exception                      90 SD     9/98      South Dakota Personal Auto Application
172 PA     2002/02   Pennsylvania Executive Officers Declaration                                   137 SD    2007/04   South Dakota Commercial Auto
Puerto Rico                                                 138 SD    2/97      South Dakota Garage and Dealers
90 PR      2004/04   Puerto Rico Personal Auto Application                                                                                 Tennessee
50 TN     2007/02   Tennessee Insurance Identification Card
90 TN     2005/01   Tennessee Personal Auto Application
133 TN    2005/10   Tennessee WC Ins Plan - Assigned Risk Supplement
137 TN    2002/01   Tennessee Commercial Auto
138 TN    2002/01   Tennessee Garage and Dealers
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                       Page 7 of 10
Number   Edition   Title                                                            Quantity    Number    Edition   Title                                                             Quantity
Texas                                                                                        Washington
50 TX     2008/11   Texas Liability Insurance Card                                                                   Notice of Information Practices (Privacy) for states
38         2008/04
60 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto
90 WA      2009/01   Washington Personal Auto Application Section
62 TX     2007/05   Texas Consumer Bill of Rights for Personal Auto (Spanish)
137 WA     2009/01   Washington Commercial Auto
64 TX     2003/04   Texas Windstorm Insurance Association Application
138 WA     2009/01   Washington Garage and Dealers
67 TX     2007/05   Texas Homeowners and Personal Property - Rights
68 TX     2007/05   Texas Homeowners and Personal Property - Rights (Spanish)
West Virginia Personal Insurance Supplement
69 TX     2000/08   Texas Special Mobile Home Windstorm/Haill Application                       38 WV      2006/04
90 TX     2001/03   Texas Personal Automobile Application                                       50 WV      2008/04   West Virginia Certificate of Insurance
137 TX    2007/08   Texas Commercial Auto                                                       60 WV      12/93     West Virginia Auto Supplement - UM/UIM Vehicle Coverage
138 TX    2007/08   Texas Garage and Dealers                                                    61 WV      2000/10   West Virginia Auto Supplement - UM Coverage Offer Split Limits
851 TX    2004/02   TX Personal Lines Supp. - Use of Credit Information Disclosure              62 WV      2000/10   West Virginia Auto Supplement - UM Coverage Offer Single Limits
TX Personal Lines Supp. (Spanish Version) - Use of Credit                                        West Virginia Essential Property Insurance Association
852 TX    2004/02                                                                               64 WV      2006/08
Information Disclosure                                                                           Basic Property Insurance Application
United States                                             65 WV      2006/05   West Virginia Umbrella Liability Supplement Important Notice
60 US     2006/04   Insurance Supplement - Offer of Terrorism Coverage                          65
2006/08   FAIR Plan Supplementary Questionnaire
Insurance Supplement - Offer of Terrorism Coverage
62 US     2006/04                                                                                                    West Virginia Umbrella Liability Supplement
Standard Fire Policy Only                                                   66 WV      2001/08
UM/UIM Coverage - Offer of Split Limits
64 US     2006/04   Insurance Supplement - Offer of Terrorism Coverage Work Comp
67         2008/04
Utah                                                                     Illinois, Indiana, Kentucky, West Virginia
61 UT     2001/02   Utah UM/UIM Coverage Selections                                                                  West Virginia Umbrella Liability Supplement
68 WV      2001/08
UM/UIM Coverage - Offer of Single Limits
63 UT     9/93      Utah Fraud Statement
90 WV      2006/01   West Virginia Personal Auto Application
66 UT     6/94      Utah Arbitration Provisions
137 WV     2006/05   West Virginia Commercial Auto
67 UT     10/94                                                                                 138 WV     2006/05   West Virginia Garage and Dealers
PIP Coverage, Loss of Income Waiver
90 UT     2001/01   Utah Personal Automobile Application                                                             West Virginia Property Supplement - Notice of Flood Coverage
862 WV     2005/07
137 UT    2001/01   Utah Commercial Auto
138 UT    2001/01   Utah Garage and Dealers
4 WI       2003/04   Wisconsin Employers First Report of Injury or Disease
90 WI      2009/10   Wisconsin Personal Auto Application
50 VT     2007/02   Vermont Automobile Insurance Identification Card
66 VT     2003/06   Vermont Insurance Supplement - Fair Credit Reporting Act                    97 WI      2003/10
Private Passenger Auto Application
90 VT     2003/06   Vermont Personal Auto Application                                           133 WI     2005/09   Wisconsin Workers Compensation Insurance Pool
137 VT    2003/06   Vermont Commercial Auto                                                     134 WI     8/99      Wisconsin Supplementary Non-Election Form
138 VT    2003/06   Vermont Garage and Dealers                                                  135 WI     8/99      Wisconsin Supplementary Election of Coverage Form
Virgin Islands                                             136 WI     7/96      Wisconsin Supplement Limited Other States Coverage Request
90 VI     2001/03   Virgin Islands Personal Auto Application                                    137 WI     2009/10   Wisconsin Commercial Auto
Virginia                                              138 WI     2009/10   Wisconsin Garage and Dealers
Notice of Information Practices (Privacy) for states                        177 WI     2003/10   Wisconsin Automobile Insurance Plan Business Auto Application
178 WI     2003/10   Wisconsin Automobile Insurance Plan - Truckers Application
60 VA     8/94      Virginia Auto Supplement - Rental Reimbursement Coverage
62 VA     6/97                                                                                  90 WY      2006/05   Wyoming Personal Automobile Application
Ordinance or Law Coverage; Additional Cov Available
64 VA     2005/01   Virginia Property Supplement - Notice of Flood Insurance                    137 WY     2006/05   Wyoming Commercial Auto
67 VA     2000/11   Virginia Property Insurance Association                                     138 WY     2006/05   Wyoming Garage and Dealers
90 VA     2005/01   Virginia Personal Auto Application
137 VA    2007/05   Virginia Commercial Auto
138 VA    2002/12   Virginia Garage and Dealers
171 VA    2003/02   Virginia Rejection of Coverage - Workers&#39; Comp Act
172 VA    2003/02   Virginia Notice Terminating Prior Rejection of Coverage
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 8 of 10
ACORD Life/Annuity Forms - Available ONLY on the ACORD Web Site
COUNTRYWIDE LIFE FORMS
Number   Edition   Title                                                                        Number    Edition   Title
650       2009/06   Authorization for the Release of Health Information                         762        2005/03   Policy Effective Date Supplement - Date of Policy Delivery
651       2007/07   Electronic Funds Transfer Authorization Form for Long Term Care Insurance   763        2005/03   Policy Effective Date Supplement - Date Policy Issued
652       2007/07   Credit Card Payment Authorization Form for Long Term Care Insurance         764        2004/03   Fair Credit Reporting Act Disclosure
653       2008/04   Policy Delivery Receipt                                                     765        2004/01   Agent&#39;s Report
701       2003/09   Life Insurance Application - Part 1                                         766        2007/03   Life Product Comparison Form
702       2004/03   Life Insurance Application - Part 2 Medical History                         767        2004/03   Temporary Insurance Agreement
703       2004/03   Medical Examiner&#39;s Report                                                                        Life Insurance Application - Part 2 Medical History Medical
768        2004/03
Condition Details / Additional Care Providers
751       2004/11   Authorization to Obtain and Disclose Information
771        2005/10   Laboratory Identification Form
752       2004/01   Illustration Certification and Acknowledgement
781        2008/01   Informal Inquiry Application - Part 2 Medical History
753       2004/07   Notice of Insurance Information Practices (Pre Notice)
782        2008/01   Medical Examiner&#39;s Report
Life Insurance Application Supplement - Additional Other
754       2003/09                                                                               783        2008/01   HIV Antibody/Antigen Consent and Testing Form
755       2003/09   Life Insurance Application Supplement - Additional Owners                                        Informal Inquiry Application - Part 2 Medical History Medical
784        2008/01
756       2003/09   Life Insurance Application Supplement - Additional Beneficiaries
951        2009/04   1035 Exchange / Rollover / Transfer Form
757       2004/07   HIV Antibody/Antigen Consent and Testing Form
758       2008/08   Life, Annuity and Health Producer Appointment Form
759       2007/03   Important Notice Regarding Replacement - Model Regulation States
760       2007/03   Important Notice Regarding Replacement
761       2005/03   Policy Effective Date Supplement - Date of Policy Application
STATE LIFE FORMS
Arizona                                                                                           Maine
751 AZ    2004/12   Arizona Authorization to Obtain and Disclose Information                    701 ME     2003/09   Maine Life Insurance Application - Part 1
757 AZ    2004/12   Arizona HIV Antibody/Antigen Consent and Testing Form                       702 ME     2004/10   Maine Life Insurance Application - Part 2 Medical History
Arkansas                                                 703 ME     2004/03   Maine Medical Examiner&#39;s Report
966 AR    2007/03   Arkansas Annuity Product Comparison Form                                    751 ME     2005/02   Maine Authorization to Obtain and Disclose Information
California                                              754 ME     2003/09
Maine Life Insurance Application Supplement - Additional Other
757 CA    2004/07   California HIV Antibody/Antigen Consent and Testing Form
757 ME     2004/07   Maine HIV Antibody/Antigen Consent and Testing Form
760 CA    2007/03   California Notice Regarding Replacement
767 ME     2005/02   Maine Temporary Insurance Agreement
966 CA    2007/03   California Annuity Product Comparison Form
Maine Life Insurance Application - Part 2 Medical History
768 ME     2004/10
District of Columbia                                                                Medical Condition Details / Additional Care Providers
757 DC    2004/07
District of Columbia HIV Antibody/Antigen Consent and Testing                                                         Maryland
701 MD     2005/06   Maryland Life Insurance Application - Part 1
702 MD     2004/09   Maryland Life Insurance Application - Part 2 Medical History
701 FL    2003/09   Florida Life Insurance Application - Part 1
703 MD     2004/09   Maryland Medical Examiner&#39;s Report
Florida Life Insurance Application Supplement - Additional Other
754 FL    2003/09                                                                               751 MD     2005/06   Maryland Authorization to Obtain and Disclose Information
755 FL    2003/09   Florida Life Insurance Application Supplement - Additional Owners                                Maryland Life Insurance Application Supplement - Additional
754 MD     2005/06
Other Proposed Insured
756 FL    2003/09   Florida Life Insurance Application Supplement - Additional Beneficiaries
Maryland Life Insurance Application Supplement - Additional
757 FL    2005/03   Florida HIV Antibody/Antigen Consent and Testing Form                       755 MD     2004/09
759 FL    2005/06   Florida Notice to Applicant Regarding Replacement of Life Insurance                              Maryland Life Insurance Application Supplement - Additional
756 MD     2004/09
966 FL    2007/03   Florida Annuity Product Comparison Form
759 MD     2005/06   Maryland Important Notice Regarding Replacement
Florida Annuity Product Comparison Form Supplement - Policy / Rider
969 FL    2007/03                                                                                                    Maryland Policy Effective Date Supplement - Date of Policy
Description                                                                 761 MD     2005/04
Maryland Policy Effective Date Supplement - Date of Policy
757 GA    2004/12   Georgia HIV Antibody/Antigen Consent and Testing Form                       762 MD     2005/04
Hawaii                                               763 MD     2005/04   Maryland Policy Effective Date Supplement - Date Policy Issued
759 HI    2007/03   Hawaii Important Notice Regarding Replacement                               767 MD     2004/12   Maryland Temporary Insurance Agreement
Idaho                                                768 MD     2005/06
Maryland Life Insurance Application - Part 2 Medical History
Medical Condition Details / Additional Care Providers
760 ID    2007/03   Idaho Important Notice Regarding Replacement
751 IN    2004/12   Indiana Authorization to Obtain and Disclose Information
767 KY    2004/12   Kentucky Temporary Insurance Agreement
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                     Page 9 of 10
STATE LIFE FORMS - continued
Number   Edition   Title                                                                          Number   Edition   Title
Massachusetts                                                                                             Ohio
701 MA    2004/08   Massachusetts Simplified Issue Life Insurance Application - Part 1            757 OH    2009/02   Ohio HIV Antibody/Antigen Consent and Testing Form
702 MA    2004/08   Massachusetts Life Insurance Application - Part 2 Medical History                                                       Oregon
753 MA    2004/08   Massachusetts Notice of Insurance Information Practices (Pre Notice)          757 OR    2004/07   Oregon HIV Antibody/Antigen Consent and Testing Form
754 MA    2004/08
Massachusetts Simplified Issue Life Insurance Application Supplement -                                              Pennsylvania
Additional Other Proposed Insured
701 PA    2004/06   Pennsylvania Life Insurance Application - Part 1
Massachusetts Simplified Issue Life Insurance Application Supplement -
755 MA    2004/08                                                                                 702 PA    2004/10   Pennsylvania Life Insurance Application - Part 2 Med History
Massachusetts Simplified Issue Life Insurance Application Supplement -                            Pennsylvania Life Insurance Application Supplement - Additional Other
756 MA    2004/08                                                                                 754 PA    2004/06
Additional Beneficiaries                                                                          Proposed Insured
757 MA    2004/11   Massachusetts HIV Antibody/Antigen Consent and Testing Form                   755 PA    2004/06   Pennsylvania Life Insurance Application Supplement - Additional Owners
760 MA    2007/03   Massachusetts Important Notice Regarding Replacement                          756 PA    2004/06   Pennsylvania Life Insurance Application Supplement - Additional Beneficiaries
761 MA    2004/08
Massachusetts Simplified Issue Policy Effective Date Supplement - Date of                                           Rhode Island
766 RI    2007/03   Rhode Island Life Product Comparison Form
Massachusetts Simplified Issue Policy Effective Date Supplement - Date of
762 MA    2004/08
Policy Delivery                                                                                                          Texas
Massachusetts Simplified Issue Policy Effective Date Supplement - Date        757 TX    2004/11   Texas HIV Antibody/Antigen Consent and Testing Form
763 MA    2004/08
759 TX    2008/02   Texas Important Notice: Replacement of Life Insurance or Annuities
Massachusetts Life Insurance Application - Part 2 Medical History - Medical
768 MA    2004/03
Condition Details / Additional Care Providers                                                                          Vermont
Michigan                                                 702 VT    2004/10   Vermont Life Insurance Application - Part 2 Medical History
757 MI    2004/12   Michigan HIV Antibody/Antigen Consent and Testing Form                        751 VT    2005/11   Vermont Authorization to Obtain and Disclose Information
Minnesota                                                 757 VT    2004/07   Vermont HIV Antibody / Antigen Consent and Testing Form
701 MN    2004/08   MN Life Insurance Application - Part 1                                        760 VT    2005/11   Vermont Important Notice Regarding Replacement
702 MN    2005/02   MN Life Insurance Application - Part 2 Medical History                                            Vermont Life Insurance Application - Part 2 Medical History Medical
768 VT    2004/10
751 MN    2005/01   Minnesota Authorization to Obtain and Disclose Information
MN Life Insurance Application Supplement - Additional Other Proposed
754 MN    2004/08                                                                                 655 VA    2009/06   Virginia Small Employer Group Health Insurance - Medical History Form
755 MN    2004/08   MN Life Insurance Application Supplement - Additional Owners                  701VA     2004/06   Virginia Life Insurance Application - Part 1
756 MN    2004/08   MN Life Insurance Application Supplement - Additional Beneficiaries           751VA     2004/12   Virginia Authorization to Obtain and Disclose Information
767 MN    2005/01   Minnesota Temporary Insurance Agreement                                                           Virginia Life Insurance Application Supplement - Additional Other Proposed
754VA     2004/06
755VA     2004/06   Virginia Life Insurance Application Supplement - Additional Owners
701 MO    2004/08   Missouri Life Insurance Application - Part 1
756VA     2004/06   Virginia Life Insurance Application Supplement - Additional Beneficiaries
Missouri Life Insurance Application Supplement - Additional Other Proposed
754 MO    2004/08                                                                                 767VA     2004/12   Virginia Temporary Insurance Agreement
755 MO    2004/08   Missouri Life Insurance Application Supplement - Additional Owners                                                   Washington
756 MO    2004/08   Missouri Life Insurance Application Supplement - Additional Beneficiaries     757 WA    2005/03   Washington HIV Antibody/Antigen Consent and Testing Form
761 MO    2004/08   Missouri Policy Effective Date Supplement - Date of Policy Application        760 WA    2005/09   Washington Important Notice Regarding Replacement
762 MO    2004/08   Missouri Policy Effective Date Supplement - Date of Policy Delivery                                                 West Virginia
763 MO    2004/08   Missouri Policy Effective Date Supplement - Date Policy Issued                757 WV    2004/07   West Virginia HIV Antibody/Antigen Consent and Testing Form
767 MO    2004/11   Missouri Temporary Insurance Agreement                                                                                Wisconsin
New Hampshire                                                 702 WI    2004/10   Wisconsin Life Insurance Application - Part 2 Medical History
757 NH    2004/07   New Hampshire HIV Antibody/Antigen Consent and Testing Form                   757 WI    2005/03   Wisconsin HIV Antibody / Antigen Consent and Testing Form
New York                                                  767 WI    2004/07   Wisconsin Temporary Insurance Agreement
751 NY    2005/11   New York Authorization to Obtain and Disclose Information                                         Wisconsin Life Insurance Application - Part 2 Medical History Medical
768 WI    2004/10
753 NY    2005/11   New York Notice of Insurance Information Practices (Pre Notice)
757 NY    2005/11   New York HIV Antibody/Antigen Consent and Testing Form
New York Important Notice Regarding Replacement or Change of Life
760 NY    2007/03
New York Disclosure Statement Regarding Replacement of Life Insurance
775 NY    2007/03
Policies or Annuity Contracts
776 NY    2007/03   New York Definition of Replacement
960 NY    2007/03   New York Disclosure Statement Annuity to Annuity Replacements Only
751 NC    2006/02   North Carolina Authorization to Obtain and Disclose Information
767 NC    2004/12   North Carolina Temporary Insurance Agreement
ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600                                                                   ACORD Forms Index (rev. 09-30-2009)
All forms are available for download on the ACORD web site (http://www.acord.org)                                                                                    Page 10 of 10
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