| Form Number |
State |
Description |
|
|
|
|
1
|
|
Property Loss Notice |
| 2 |
|
Automobile Loss Notice |
| 3 |
|
Gen Liab Notice Occ/Claim (3 part) |
| 4 |
|
Workers Comp 1st Rpt of Injury or Illness |
| 11 |
|
Auto Accident Information Form |
| 12 |
|
Exchange of Information Form |
| 13 |
|
Witness Card |
| 18 |
|
Jewelry Appraisal & Claim Evaluation |
| 23 |
|
Leased Auto Certificate of Insurance |
| 24 |
|
Cert of Property Ins |
| 25-N |
|
Cert of Liability Ins |
| 25-S |
|
Cert of Liability Ins (incl Form #26) |
| 26 |
|
Policy Certification Log |
| 27 |
|
Evidence of Property Ins |
| 35 |
|
Cancel Reqst/Policy Release |
| 36 |
|
Agent/Broker of Record Change |
| 37 |
|
Statement of No Loss |
| 38 |
|
Notice of Information Practices (Privacy) |
| 38 |
AZ |
Notice of Information Practices (Privacy) |
| 40 |
|
Residential Property Valuation Survey |
| 41 |
|
Residential Property Replacement |
|
|
Cost Worksheet |
| 42 |
|
Residential Property Replacement Cost |
|
|
Information Supplement |
| 45 |
|
Additional Interest |
| 50 |
|
Insurance ID Card |
| 50 |
FL |
FL Auto Ins ID Card (2 part) |
| 50 |
HI |
HI Motor Vehicle Ins ID Card |
| 50 |
KY |
Commonwealth of KY Proof of Ins (2 part) |
| 50 |
LA |
LA Auto Ins ID Card (2 part) |
| 50 |
MI |
MI Cert of No-Fault Ins (2 part) |
| 50 |
MO |
MO Auto Insurane Identification Card (2part) |
| 50 |
NY |
NY State Insurance Identification Card (w/watermark) |
| 50 |
OK |
OK Security Verification Form (2 part) |
| 50 |
TX |
TX Liab Ins Card |
| 50 |
WV |
WV Cert of Ins (2 part) (ID card) |
| 50 WM |
|
Insurance ID Card (W/Watermark) |
| 54 |
|
Financial Responsibility Form (3part) |
| 57 |
|
Financial Responsibility Form (Notice of |
|
|
Cancellation or Termination) (3 part) |
| 60 |
|
Flood Insurance Notice/Rejection |
| 60 |
HI |
HI Auto Supp, UM/UIM |
| 60 |
LA |
LA Homeowners Supp-Loss Settlement |
| 60 |
NM |
Confidential Abuse Information Disclosure Notice |
| 60 |
NY |
NY Homeowners Supp |
| 60 |
OK |
Ok Auto Supp OK UM Cov Law |
| 60 |
PA |
PA Auto Supp, UM Cov Select/Reject |
| 60 |
TX |
TX Auto Supp Cons Bill Rights Pers Auto |
| 60 |
VA |
VA Auto Supp Rental Reim Cov |
| 60 |
WV |
WV Auto Supp UM/UIM Vehicle |
| 61 |
AK |
AK Auto Supplement, UM/UIM Cov. Selection Form |
| 61 |
AR |
AR Auto Supp, UM/UIM Coverage Selection |
| 61 |
AZ |
AZ Personal Auto Supp, Consumer Information |
| 61 |
CA |
CA Auto Supp, UM Bl Offr |
| 61 |
CO |
CO Auto Supp, Summary of Cov |
| 61 |
CT |
CT Auto Supp, UM Cov |
| 61 |
DE |
DE Auto Supp UM |
| 61 |
FL |
FL Auto Supp, Reject/Elect UM |
| 61 |
GA |
GA Auto Supp, UM Cov and Medical |
| 61 |
IA |
IA Auto Supp, UM and UIM Offer/Reject |
| 61 |
IL |
IL Auto Supp, UM/UIM |
| 61 |
LA |
Louisana Homeowners Supplement Loss Settlement |
| 61 |
MD |
MD Personal Auto Supp, |
| 61 |
NC |
NC Auto Supp Selection/Rejection Form, Uninsured Motorists |
| 61 |
NJ |
NJ Auto Supp Cov Select Form |
| 61 |
NV |
NV Auto Supp, Mand Offr Med Pay & UM |
| 61 |
NY |
NY Auto Supp Opt Basic Econ Loss (OBEL) |
| 61 |
OK |
OK Auto Supp Elect of Non-Stacked Cov |
| 61 |
OR |
OR Auto Supp UM Cov Select |
| 61 |
PA |
PA Auto Supplement |
| 61 |
RI |
RI Auto Supp UM/UIM BI Coverage |
| 61 |
SC |
SC Auto Supp Purchasing Auto Ins. |
| 61 |
WI |
WI Auto Supp, UIM Coverage |
| 61 |
WV |
WV UM Cov Offer - Split Limits |
| 62 |
AK |
AK Auto Supplement, Exclusion of Named Drivers |
|
|
From Auto Insurance Coverage |
| 62 |
AL |
AL Insurance Application Supplement |
| 62 |
AZ |
Arizona Commercial Auto Supplement |
| 62 |
CA |
CA Auto Preinspection Law |
| 62 |
CO |
CO Personal Property Supplement |
| 62 |
IA |
IA Auto Supplement, Notice Regarding UM/UIM Coverage |
| 62 |
LA |
LA Comm Property Supp |
| 62 |
MD |
MD Commercial Auto Supplement |
| 62 |
MI |
MI Collision Ins Options Notice |
| 62 |
NC |
NC JUA/IUA Fair and Beach Plan Cov |
| 62 |
NH |
NH Statement of Residency or Exemption |
| 62 |
NV |
NV Umbrella Supplement |
| 62 |
PA |
PA Auto Supp, UIM Cov Select/Reject |
| 62 |
SC |
SC Comm Auto Supp |
| 62 |
TX |
TX Auto Supp Cons Bill Rights (Spanish) |
| 62 |
VA |
VA Property Supplement, Ordiance or Law Coverage |
|
|
Additional Coverage Available |
| 62 |
WA |
WA Auto Supp Mand Offer PIP Cov |
| 62 |
WV |
WV UM/UIM Cov Offer Sng Lim |
| 63 |
|
General Fraud Statement |
| 63 |
CO |
CO Applicant Supplement, Fraud Warning |
| 63 |
HI |
HI Fraud Statement |
| 63 |
OH |
OH Fraud Statement |
| 63 |
OK |
OK Fraud Statement |
| 63 |
UT |
UT Fraud Statement |
| 64 |
CA |
CA Ins Supp, Agency Lang Form |
| 64 |
IA |
IA Auto Supplement, UM/UIM Stacking Cov Option Notice |
| 64 |
LA |
LA Homeowners Supplement-Loss Settlement |
|
|
for use with HO2 & 3 |
| 64 |
MA |
MA Residential Property Liability Supplement |
| 64 |
MD |
MD Property Insurance Availability Program, Essential |
|
|
Property Insurance Inspection and Placement (4part) |
| 65 |
CA |
CA Ins Supp, Race, Nat Orig, Gender Form |
| 65 |
LA |
LA Homeowners Supplement-Loss Settlement |
|
|
for use with HO6 |
| 65 |
MN |
MN Guaranty Assoc Notice |
| 66 |
AR |
AR Insurance Supplement |
| 66 |
CA |
CA Offer of Earthquake Coverage |
| 66 |
FL |
FL Insurance Supplement, Credit Report Disclosure Information |
| 66 |
LA |
LA Dwelling Supplement-Loss Settlement |
|
|
for use with DWG2 & 3 |
| 66 |
NC |
NC Insurance Supplement, Consent to Obtain a Credit |
|
|
Report or Investigative Consumer Report |
| 66 |
UT |
UT Arbitration Provisions |
| 66 |
VT |
VT Ins Supp Fair Crdt Reprtng Act |
| 67 |
|
IL, IN, KY, WV Mine Sub Home & Dw Supp |
| 67 |
CA |
CA Residential Property Disclosure |
| 67 |
FL |
FL Homeowners Supp |
| 67 |
LA |
LA Certification of Mobile Home Tie Downs |
| 67 |
OH |
OH Mine Subsidence Home and Dwell |
| 67 |
TX |
TX Homeowners and Personal Prop Supp |
| 67 |
UT |
UT Auto, PIP Cov, Waiv Loss Income |
| 68 |
LA |
LA Plan Services Application for Insurance |
| 68 |
ND |
ND Supp to Prop Ins App |
| 68 |
OH |
OH Offer of Mine Sub Ins HO & Dwell |
| 68 |
TX |
TX Homeowners and Pers Prop Supp (Spanish) |
| 69 |
LA |
Auto Supplement-UM/UIM Bodily Injury Coverage Form |
|
|
UM Property Damage Coverage |
| 70 |
|
Personal Policy Change Request (except Auto) |
| 71 |
|
Personal Auto Policy Change Request |
| 71 |
SC |
SC Private Passenger Policy Change Request |
| 75-N |
|
Ins Binder |
| 75-S |
|
Ins Binder (incl Form #76) |
| 76 |
|
Binder Log |
| 78 |
|
Jewelry Insurance Appraisal -- Single Item |
| 79 |
|
Jewelry Insurance Appraisal |
| 80 |
|
Homeowner App |
| 80 |
MN |
Minnesota Homeowners Application |
| 81 |
|
Personal Inland Marine App |
| 82 |
|
Watercraft App |
| 83 |
|
Personal Umbrella App |
| 84 |
|
Dwelling Fire App |
| 85 |
|
Mobile Home App |
| 86 |
|
Personal Lines Pkg App |
| 87 |
|
PL Pkg App Watercraft/Inland marine Supp |
| 90 |
AK |
AK Personal Auto App |
| 90 |
AL |
AL Personal Auto App |
| 90 |
AR |
AR Personal Auto App |
| 90 |
AZ |
AZ Personal Auto App |
| 90 |
CA |
CA Personal Auto App |
| 90 |
CO |
CO Personal Auto App |
| 90 |
CT |
CT Personal Auto App |
| 90 |
DC |
DC Personal Auto App |
| 90 |
DE |
DE Personal Auto App |
| 90 |
FL |
FL Personal Auto App |
| 90 |
GA |
GA Personal Auto App |
| 90 |
HI |
HI Personal Auto App |
| 90 |
IA |
IA Personal Auto App |
| 90 |
ID |
ID Personal Auto App |
| 90 |
IL |
IL Personal Auto App |
| 90 |
IN |
IN Personal Auto App |
| 90 |
KS |
KS Personal Auto App |
| 90 |
KY |
KY Personal Auto App |
| 90 |
LA |
LA Personal Auto App |
| 90 |
MA |
MA Personal Auto App |
| 90 |
MD |
MD Personal Auto App |
| 90 |
ME |
ME Personal Auto App |
| 90 |
MI |
MI Personal Auto App |
| 90 |
MN |
MN Personal Auto App |
| 90 |
MO |
MO Personal Auto App |
| 90 |
MS |
MS Personal Auto App |
| 90 |
MT |
MT Personal Auto App |
| 90 |
NC |
NC Personal Auto App |
| 90 |
ND |
ND Personal Auto App |
| 90 |
NE |
NE Personal Auto App |
| 90 |
NH |
NH Personal Auto App |
| 90 |
NJ |
NJ Personal Auto App |
| 90 |
NM |
NM Personal Auto App |
| 90 |
NV |
NV Personal Auto App |
| 90 |
NY |
NY Personal Auto App |
| 90 |
OH |
OH Personal Auto App |
| 90 |
OK |
OK Personal Auto App |
| 90 |
OR |
OR Personal Auto App |
| 90 |
PA |
PA Personal Auto App |
| 90 |
PR |
PR Personal Auto Application |
| 90 |
RI |
RI Personal Auto App |
| 90 |
SC |
SC Personal Auto App |
| 90 |
SD |
SD Personal Auto App |
| 90 |
TN |
TN Personal Auto App |
| 90 |
TX |
TX Personal Auto App |
| 90 |
UT |
UT Personal Auto App |
| 90 |
VA |
VA Personal Auto App |
| 90 |
VT |
VT Personal Auto App |
| 90 |
WA |
WA Personal Auto App |
| 90 |
WI |
WI Personal Auto App |
| 90 |
WV |
WV Personal Auto App |
| 90 |
WY |
WY Personal Auto App |
| 91 |
|
Good Student/Driver Training |
| 92 |
|
Medical Statement |
| 93 |
|
Young Driver Questionnaire |
| 94 |
HI |
HI Vehicle Inspection Report Supp |
| 94 |
NJ |
NJ Ins Inspection Report |
| 95 |
MA |
MA Statement of Facts Renewal App |
| 97 |
SC |
SC Private Passenger Auto Application |
| 97 |
WI |
WI Automobile Insurance Plan, Private Passenger Auto App. |
| 125 |
|
Comm Ins App - Applicant Info Sect |
| 126-N |
|
General Liability Section |
| 126-S |
|
Comm Gen Liab Sect |
| 127 |
|
Business Auto Sect |
| 128 |
|
Garage and Dealers Sect |
| 129 |
|
Vehicle Schedule |
| 129 |
SC |
SC Vehicle Schedule |
| 130 |
|
Workers Comp App |
| 130 |
FL |
FL Workers Comp App |
| 131 |
|
Umbrella Section |
| 132 |
|
Truckers/Motor Carriers Sect |
| 133 |
|
Work Comp Ins Plan Assigned Risk Sect |
| 133 |
FL |
FL Workers Comp. Joint Underwriting Assoc. Inc., |
|
|
Addendum to ACORD 130 FL |
| 133 |
MT |
MT State Compensation Insurance Fund, Worker’s |
|
|
Compensation Application Supplement |
| 133 |
NC |
NC Workers Com. Insurance Plan, App. for |
|
|
Designation of An Insurance Company |
| 133 |
NJ |
NJ W/C Ins Plan, App for Desig Ins Co |
| 133 |
PA |
PA State Workers’ Insurance Fund, Application for Workers’ |
|
|
Compensation Insurance |
| 133 |
WI |
WI Workers Compensation Insurance Pool |
| 134 |
FL |
FL Workers Compensation Joint Underwriting Association, Inc., |
|
|
Inst. for Completing ACORD 130 FL and ACORD 133 FL |
| 134 |
NC |
NC Workers Com. Insurance Plan, Inst. for Completing |
|
|
ACORD 133 NC Application |
| 134 |
NJ |
NJ W/C Ins Plan, Supp Empl Leasing App |
| 134 |
WI |
WI Supplementary Non-Election Form |
| 135 |
NJ |
NJ W/C Ins Plan, Truckers Supp App |
| 135 |
WI |
WI Supplementary Election of Coverage Form |
| 136 |
NJ |
NJ W/C Ins Plan, Instructions & Rules |
| 136 |
WI |
WI Suppl. Limited Other States Coverage Request |
| 137 |
AK |
AK Comm Auto Sect |
| 137 |
AL |
AL Comm Auto Sect |
| 137 |
AR |
AR Comm Auto Sect |
| 137 |
AZ |
AZ Comm Auto Sect |
| 137 |
CA |
CA Comm Auto Sect |
| 137 |
CO |
CO Comm Auto Sect |
| 137 |
CT |
CT Comm Auto Sect |
| 137 |
DC |
DC Comm Auto Sect |
| 137 |
DE |
DE Comm Auto Sect |
| 137 |
FL |
FL Comm Auto Sect |
| 137 |
GA |
GA Comm Auto Sect |
| 137 |
HI |
HI Comm Auto Sect |
| 137 |
IA |
IA Comm Auto Sect |
| 137 |
ID |
ID Comm Auto Sect |
| 137 |
IL |
IL Comm Auto Sect |
| 137 |
IN |
IN Comm Auto Sect |
| 137 |
KS |
KS Comm Auto Sect |
| 137 |
KY |
KY Comm Auto Sect |
| 137 |
LA |
LA Comm Auto Sect |
| 137 |
MA |
MA Comm Auto Sect |
| 137 |
MD |
MD Comm Auto Sect |
| 137 |
ME |
ME Comm Auto Sect |
| 137 |
MI |
MI Comm Auto Sect |
| 137 |
MN |
MN Comm Auto Sect |
| 137 |
MO |
MO Comm Auto Sect |
| 137 |
MS |
MS Comm Auto Sect |
| 137 |
MT |
MT Comm Auto Sect |
| 137 |
NC |
NC Comm Auto Sect |
| 137 |
ND |
ND Comm Auto Sect |
| 137 |
NE |
NE Comm Auto Sect |
| 137 |
NH |
NH Comm Auto Sect |
| 137 |
NJ |
NJ Comm Auto Sect |
| 137 |
NM |
NM Comm Auto Sect |
| 137 |
NV |
NV Comm Auto Sect |
| 137 |
NY |
NY Comm Auto Sect |
| 137 |
OH |
OH Comm Auto Sect |
| 137 |
OK |
OK Comm Auto Sect |
| 137 |
OR |
OR Comm Auto Sect |
| 137 |
PA |
PA Comm Auto Sect |
| 137 |
RI |
RI Comm Auto Sect |
| 137 |
SC |
SC Comm Auto Sect |
| 137 |
SD |
SD Comm Auto Sect |
| 137 |
TN |
TN Comm Auto Sect |
| 137 |
TX |
TX Comm Auto Sect |
| 137 |
UT |
UT Comm Auto Sect |
| 137 |
VA |
VA Comm Auto Sect |
| 137 |
VT |
VT Comm Auto Sect |
| 137 |
WA |
WA Comm Auto Sect |
| 137 |
WI |
WI Comm Auto Sect |
| 137 |
WV |
WV Comm Auto Sect |
| 137 |
WY |
WY Comm Auto Sect |
| 138 |
AK |
AK Garage and Dealers Sect |
| 138 |
AL |
AL Garage and Dealers Sect |
| 138 |
AR |
AR Garage and Dealers Sect |
| 138 |
AZ |
AZ Garage and Dealers Sect |
| 138 |
CA |
CA Garage and Dealers Sect |
| 138 |
CO |
CO Garage and Dealers Sect |
| 138 |
CT |
CT Garage and Dealers Sect |
| 138 |
DC |
DC Garage and Dealers Sect |
| 138 |
DE |
DE Garage and Dealers Sect |
| 138 |
FL |
FL Garage and Dealers Sect |
| 138 |
GA |
GA Garage and Dealers Sect |
| 138 |
HI |
HI Garage and Dealers Sect |
| 138 |
IA |
IA Garage and Dealers Sect |
| 138 |
ID |
ID Garage and Dealers Sect |
| 138 |
IL |
IL Garage and Dealers Sect |
| 138 |
IN |
IN Garage and Dealers Sect |
| 138 |
KS |
KS Garage and Dealers Sect |
| 138 |
KY |
KY Garage and Dealers Sect |
| 138 |
LA |
LA Garage and Dealers Sect |
| 138 |
MA |
MS Garage and Dealers Sect |
| 138 |
MD |
MD Garage and Dealers Sect |
| 138 |
ME |
ME Garage and Dealers Sect |
| 138 |
MI |
MI Garage and Dealers Sect |
| 138 |
MN |
MN Garage and Dealers Sect |
| 138 |
MO |
MO Garage and Dealers Sect |
| 138 |
MS |
MA Garage and Dealers Sect |
| 138 |
MT |
MT Garage and Dealers Sect |
| 138 |
NC |
NC Garage and Dealers Sect |
| 138 |
ND |
ND Garage and Dealers Sect |
| 138 |
NE |
NE Garage and Dealers Sect |
| 138 |
NH |
NH Garage and Dealers Sect |
| 138 |
NJ |
NJ Garage and Dealers Sect |
| 138 |
NM |
NM Garage and Dealers Sect |
| 138 |
NV |
NV Garage and Dealers Sect |
| 138 |
NY |
NY Garage and Dealers Sect |
| 138 |
OH |
OH Garage and Dealers Sect |
| 138 |
OK |
OK Garage and Dealers Sect |
| 138 |
OR |
OR Garage and Dealers Sect |
| 138 |
PA |
PA Garage and Dealers Sect |
| 138 |
RI |
RI Garage and Dealers Sect |
| 138 |
SC |
SC Garage and Dealers Sect |
| 138 |
SD |
SD Garage and Dealers Sect |
| 138 |
TN |
TN Garage and Dealers Sect |
| 138 |
TX |
TX Garage and Dealers Sect |
| 138 |
UT |
UT Garage and Dealers Sect |
| 138 |
VA |
VA Garage and Dealers Sect |
| 138 |
VT |
VT Garage and Dealers Sect |
| 138 |
WA |
WA Garage and Dealers Sect |
| 138 |
WI |
WI Garage and Dealers Sect |
| 138 |
WV |
WV Garage and Dealers Sect |
| 138 |
WY |
WY Garage and Dealers Sect |
| 139 |
|
Statement/Schedule of Values |
| 139 |
MS |
MS Statement/Schedule of Values |
| 140 |
|
Property Sect |
| 141 |
|
Crime Sect |
| 143 |
|
Transportation Sect |
| 144 |
|
Glass and Sign Supp |
| 145 |
|
Accounts Receivable/Valuable Papers |
| 146 |
|
Equipment Floater Sect |
| 147 |
|
Installation/Builders Risk Sect |
| 148 |
|
Electronic Data Processing Sect |
| 149 |
|
Dealers Section |
| 151 |
|
Miscellaneous Crime Coverage Sect |
| 154 |
|
Jeweler’s Inventory Record-Keeping Card |
| 155 |
|
Boiler & Machinery Sect |
| 160 |
|
Business Owners App |
| 161 |
|
Business Owners Supp App |
| 163 |
|
Commercial Auto Driver Information Schedule |
| 165 |
|
Small Comm Account Pkg App |
| 171 |
AK |
AK Petition for Executive Officer Waiver |
| 171 |
CO |
CO Rejection of Coverage by Corporate Officers |
| 171 |
CT |
CT Workers Comp Commission of CT Coverage Selection |
|
|
Form for Employee Who is an Officer of the Corporation |
| 171 |
DE |
DE Workers Compensation Election |
| 171 |
FL |
FL Notice of Election of Coverage Under Workers Comp. Law |
| 171 |
GA |
GA State Board of Workers Comp.Corporate Officer Rejection |
| 171 |
KS |
KS Election of Individual Partner or Self Employed Individual |
| 171 |
MI |
MI App. For Exclusion of Partner(s), Spouse, Child or Parent |
| 171 |
NM |
NM Executive Employee |
