ACORD Forms Index - Frequently Used

1 ACORD Forms Index Please provide the information below to avoid delay in shipment. Agency/Company Name: Contact Name: Street Address: City: State: Zip: Telephone: ACORD Account #: Fax: E-Mail Address: Web Site: All packages contain 100 Forms - Please specify number of packages required COUNTRYWIDE P&C Forms . # Current Future Title Quantity # Current Future Title Quantity 1 2013/01 Property Loss Notice 70 2015/09 Personal Policy Change Request (Except Auto). 2 2013/01 Automobile Loss Notice 71 2015/09 Personal Auto Policy Change Request 3 2013/01 General Liability Notice of Occur/Claim 72 2009/10 Mobile Home Supplement 4 2013/01 Workers Compensation - First Report of Injury or Illness 73 2009/07 Solid Fuel Questionnaire - Supplement to Residential Section 5 2013/01 Aircraft Loss Notice Residence Based Business 74 2009/09.

2 Supplement to Residential Section 6 2009/05 Aviation Witness / Passenger Schedule 75 2016/03 Insurance Binder 7 2009/05 Aviation Injured Schedule 76 9/93 Binder Log 11 2/95 Auto Accident Information form 80 2016/03 Homeowner Application 12 2/95 Exchange of Information form 81 2016/03 Personal Inland Marine Application 13 2/95 Witness Card 82 2016/03 Watercraft Application 20 2016/03 Certificate of Aviation Liability Insurance 83 2016/04 Personal Umbrella Application 21 2016/03 Certificate of Aircraft Insurance 84 2016/03 Dwelling Fire Application 22 2016/03 Intermodal Interchange Certificate of Insurance 85 2016/03 Mobile Home Application 23 2016/03 Vehicle or Equipment Certificate of Insurance Personal Insurance Application - Applicant Information 24 2016/03 Certificate of Property Insurance 88 2015/12.

3 Section 25 2016/03 Certificate of Liability Insurance 89 2016/03 Residential Section 26 2002/01 Policy Certification Log 91 2009/10 Good Student Driver Training 27 2016/03 Evidence of Property Insurance 92 2012/03 Medical Statement 28 2016/03 Evidence of Commercial Property Insurance 93 2012/03 Young Driver Questionnaire 29 2016/03 Evidence of Flood Insurance 99 2009/02 Accidents / Convictions Schedule 30 2016/03 Certificate of Garage Insurance 101 2008/01 Additional Remarks Schedule 31 2016/03 Certificate of Marine / Energy Insurance Personal Auto Application Schedule - Additional Resident 103 2012/03.

4 And Driver Information Section 35 2016/03 Cancellation Request / Policy Release 105 2012/06 Apartment Building Supplement 36 2007/01 Agent/Broker of Record Change 106 2010/04 Vacant Building Supplement 37 2008/01 Statement of No Loss Commercial Insurance Application 38 2013/01 Notice of Insurance Information Practices (Privacy) 125 2016/03. Applicant Information Section 42 2014/08 Residential Property Replacement Cost 126 2016/03 2016/09 Commercial General Liability Section 45 2016/03 Additional Interest Schedule 127 2015/12 Business Auto Section 50 2007/02 Automobile Insurance ID Card 128 2015/12 Garage and Dealers Section 50 WM 2007/03 Automobile Insurance ID Card (with Watermark)

5 129 2009/11 Vehicle Schedule 54 1/97 Financial Responsibility form 130 2013/09 Workers Compensation Application 57 1/97 Financial Responsibility form - Cancellation 131 2016/04 Umbrella Section 58 2007/11 Notice of Cancellation or Termination of Policy 132 2015/12 Truckers / Motor Carriers Section 60 2010/04 Flood Insurance Selection / Rejection Workers Compensation Insurance Plan - Assigned Risk 133 2016/03. Section 60 US 2015/01 Insurance Supplement - Notice - Offer of Terrorism Coverage 139 2015/12 Statement / Schedule of Values Insurance Supplement - Standard Fire Policy Only 62 US 2015/01 140 2016/03 Property Section Notice - Offer of Terrorism Coverage 63 2016/04 Fraud Statements 141 2016/03 Crime Section Insurance Supplement - Workers' Compensation Only 143 2013/09 Transportation Section 64 US 2015/01.

6 Notice - Offer of Terrorism Coverage 144 2013/09 Glass And Sign Section Personal Insurance Supplement - Extraordinary Life 66 2011/05 145 2013/09 Accounts Receivable / Valuable Papers Circumstances 68 2016/06 Electronic Delivery Supplement 147 2016/03 Installation / Builders Risk Section Future Forms are intended for use on or after the first day of the edition date month. ( , edition date 2016/01 for use on or after 1/1/2016). ACORD Member Services - Phone: (845) 620-1700, Option 2 - Fax: (845) 620-3600 ACORD Forms Index (rev.)

7 05-31-2016). All Forms are available for download on the ACORD web site ( ) Page 1 of 12. ACORD Forms Index All packages contain 100 Forms - Please specify number of packages required COUNTRYWIDE P&C Forms - continued # Current Future Title Quantity # Current Future Title Quantity 148 2016/03 Electronic Data Processing Section 340 2016/03 Aircraft Change Request 149 2013/09 Dealers Section 341 2011/11 Pilot Experience Change Request 152 2015/06 Commercial Inland Marine Section 342 2009/06 Hangar Change Request 155 BM 2014/12 2016/09 Boiler & Machinery 2002 / Equipment Breakdown Section

8 350 Watermark Paper - 20 # ID Card Stock (4-part perforation). 159 2014/09 Schedule of Insurance 360 Watermark Paper - 32 # ID Card Stock (4-part perforation). 160 2015/06 2016/09 Business Owners Section 370 Watermark Paper - 32 # ID Card Stock (non-perforated). 163 2012/06 Commercial Auto Driver Information Schedule 401 2016/03 Agriculture Application 175 2016/03 Commercial Policy Change Request 402 2016/03 Agriculture Property Section Technology E&O Section - Electronic Data Processors, Agriculture Property Section 180 2016/03 403 2016/03.

9 Electronic Products Manufacturers, Computer Services etc. Scheduled / Unscheduled Personal Property 185 2011/09 Restaurant / Tavern Supplement 404 2016/03 Agriculture Liability Section 186 2011/10 Contractors Supplement 405 2007/09 Agriculture Premises Diagram 187 2016/03 Professional Liability Supplement Agriculture Supplement - Unscheduled Farm Personal 406 2007/09. Property Inventory form 190 2013/09 Supplemental Property Application 407 2016/03 Livestock Mortality Section 193 2013/09 Open Cargo Section 408 2007/09 Equine Liability Supplement 194 2009/03 Truckers / Motor Carrier Supplement 410 2016/03 Small Farm / Ranch Application 195 10/96 Design Professional's Individual Property Survey 501 2016/06 Surety Report of Execution 196 2013/09 Medical Professional Liability Insurance Application 502 2015/04 Contract Bond Request form 199 1/99 Application Supplement

10 - Undertaking 503 2016/06 Commercial and Miscellaneous Bond Request form 200 3/93 Producer Account 504 2016/06 Additional Entity Schedule 201 3/93 Producer Account Discrepancy Notice 610 2015/12 Premium Payment Supplement 210 2016/03 Yacht Section 611 2015/07 Claims History / Loss Run Request 211 2016/09 Schedule of Hazards 801 2002/01 Railroad Protective Liability Supplement 225 1/98 Policyholder's Report 802 2011/09 Hotel / Motel Supplement 226 3/93 Statement of Premium Adjustment 803 2016/03 Liquor Liability Section 275 2016/03 Aviation Insurance Binder 807 2016/03 Directors & Officers Liability Section 276 2016/03 Aircraft Insurance Binder 808 2010/08 P&C Agency Appointment form 281 2016/05 Personal Inland Marine Section Business Income / Extra Expense / Rental Value 282 2016/05 Watercraft Section 810 2014/12.