ACORD Forms Notification Service June 2013 Bulletin

ACORD Forms Notification Service
June 2013 Bulletin
ACORD P&C and Life/Annuity/Health Form Changes and Additions
The following pages include both a List of recently revised ACORD forms and an Explanation of the Changes
made.
Beginning this month, we have made an enhancement to our filing and forms release processes. Whenever
possible, new and revised ACORD forms will be made available one to six months in advance of the form
effective date. In these instances, companies will have this additional time to implement the forms into
their systems before the current versions are replaced. Both the current versions and the revised future
effective date versions will be found on the Forms Download page at www.acord.org. The effective date
included on the footer of all forms will match the date the form must be used in all jurisdictions in order to
ensure compliance with our filings.
Copies of the forms referenced in this announcement can be downloaded in the formats you need at
www.acord.org. To download forms, you will need to “sign-in” as an ACORD member with your user name and
password. Once you are signed in, click on the Forms button, and then click on Download Forms to access the
ones you need. If you need assistance, a sample of a form, or are an agent / broker who would like to join
the Advantage Program, please call Member Services at (800) 444-3341, Option 2 or email us at
memberservices@acord.org.
If you do not wish to receive this notification, please send an email to memberservices@acord.org requesting
that we unsubscribe you to this Forms Notification Service.
ACORD Forms Notification 06-28-2013

ACORD Forms Release 06-28-2013
Form Number Replaces Title Effective
Date
REVISIONS
P&C - Countrywide
25 (2014/01) 2010/05 Certificate of Liability Insurance 1/1/2014
28 (2014/01) 2011/11 Evidence of Commercial Property Insurance 1/1/2014
30 (2014/01) 2010/12 Certificate of Garage Insurance 1/1/2014
31 (2014/01) 2012/08 Certificate of Marine / Energy Insurance 1/1/2014
*125 (2013/09) 2013/01 Commercial Insurance Application 9/1/2013
143 (2013/09) 2004/01 Transportation Section 9/1/2013
144 (2013/09) 2011/10 Glass and Sign Section 9/1/2013
145 (2013/09) 2004/03 Accounts Receivable / Valuable Papers 9/1/2013
146 (2013/09) 2007/02 Equipment Floater Section 9/1/2013
147 (2013/09) 2001/02 Installation / Builders Risk Section 9/1/2013
148 (2013/09) 2000/02 Electronic Data Processing Section 9/1/2013
190 (2013/09) 2013/01 Supplemental Property Application 9/1/2013
*196 (2013/09) 2013/01 Medical Professional Liability Insurance
9/1/2013
Application
401 (2013/09) 2013/01 Agriculture Application 9/1/2013
410 (2013/09) 2013/01 Small Farm / Ranch Application 9/1/2013
825 (2013/09) 2013/01 Professional / Specialty Insurance Application 9/1/2013
P&C - State Specific
132 NJ (2013/07) 2006/07 New Jersey Workers Compensation Insurance 7/1/2013
Plan, Instructions and Rules
133 NJ (2013/07) 2008/09 New Jersey Workers Compensation Insurance 7/1/2013
Plan, Application for Designation of an
Insurance Company
137 AR (2013/10) 2010/08 Arkansas Commercial Auto 10/1/2013
854 CA (2013/07) 2013/01 California FAIR Plan Property Insurance, 7/1/2013
Application for Dwelling Insurance
855 CA (2013/07) 2013/01 California FAIR Plan Property Insurance,
Application for Commercial Insurance
7/1/2013
Life/Annuity/Health
NONE
* indicates an e-label change in addition to the form revision. See rows highlighted in
yellow in the excel Mapping spreadsheet.
1 of 2 ACORD Forms Release 06-28-2013

ACORD Forms Release 06-28-2013
Form Number Replaces Title Effective
Date
NEW
P&C - Countrywide
P&C – State
Specific
NONE
NONE
Life/Annuity/Health
NONE
WITHDRAWN
861 FL (2013/01) Withdrawn Florida Auto Supplement – Notification of
Personal Injury Protection Benefits
6/28/2013
FIG ONLY
24 (2009/09) Certificate of Property Insurance 6/20/2013
35 (2011/09) Cancellation Request / Policy Release 6/12/2013
E-FORM
CONVERSIONS
NONE
2 of 2 ACORD Forms Release 06-28-2013

Explanation of Changes 06-28-2013
Countrywide – Revised
P&C FORMS
25 (2014/01)
Certificate of Liability Insurance
1. Reduce font size of title to 14 pt bold
2. COVERAGES section, revise second column header to ADDL INSD
3. COVERAGES section, first row of data, delete GENERAL LIABILITY header, move all
checkboxes up and bold COMMERCIAL GENERAL LIABILITY checkbox label
4. COVERAGES section, first row of data, GEN’L AGGREGATE LIMIT APPLIES PER:, add an
OTHER: checkbox with a field to capture description
5. COVERAGES section, WORKERS COMPENSATION row of data, in LIMITS column on right,
revise WC STATUTORY LIMITS to PER STATUTE
6. Revise text in parentheses in DESCRIPTION OF OPERATIONS header
7. Revise ACORD copyright to 1988-2014
28 (2014/01)
Evidence of Commercial Property Insurance
1. COVERAGE INFORMATION section, revise WIND / HAIL label to WIND / HAIL INCL
and add YES and NO checkboxes and revise and move Subject to Different Provisions to
right
2. Add new row labeled NAMED STORM INCL
3. Delete last blank row
4. Move ACORD form number down, interferes with postal scanning
5. Revise ACORD copyright to 2003-2014
30 (2014/01)
Certificate of Garage Insurance
1. Reduce font size of title to 14 pt bold
2. COVERAGES section, third row of data, delete GENERAL LIABILITY header, move all
checkboxes up and bold COMMERCIAL GENERAL LIABILITY checkbox label
3. COVERAGES section, third row of data, GEN’L AGGREGATE LIMIT APPLIES PER:, add an
OTHER: checkbox with a field to capture description
4. COVERAGES section, WORKERS COMPENSATION row of data, in LIMITS column on right,
revise WC STATUTORY LIMITS to PER STATUTE
5. Revise text in parentheses in REMARKS header
6. Revise ACORD copyright to 2010, 2014
1 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
31 (2014/01)
Certificate of Marine / Energy Insurance
Page 1
1. Revise ACORD copyright to 2012, 2014
Page 2
2. COVERAGES section, first row of data, delete GENERAL LIABILITY header, move all
checkboxes up and bold COMMERCIAL GENERAL LIABILITY checkbox label
3. COVERAGES section, first row of data, GEN’L AGGREGATE LIMIT APPLIES PER:, add an
OTHER: checkbox with a field to capture description
4. COVERAGES section, WORKERS COMPENSATION row of data, in LIMITS column on right,
revise WC STATUTORY LIMITS to PER STATUTE
5. COVERAGES section, U.S. LONGSHORE AND HARBOR WORKERS COMPENSATION row
of data, in LIMITS column on right, revise STATUTORY LIMITS to PER STATUTE
125 (2013/09)
Commercial Insurance Application
Applicant Information Section
Page 1
1. SECTIONS ATTACHED section, delete MISCELLANEOUS CRIME from the CRIME /
MISCELLANEOUS CRIME checkbox label. Miscellaneous Crime form was incorporated into
the Crime Section.
Page 4
1. LOSS HISTORY section, delete last row in table
2. SIGNATURE section, delete first paragraph and revise all remaining fraud warnings. Use
state abbreviations in all paragraph titles
3. SIGNATURE section, add fraud warning for KY, NY, OH and PA
4. SIGNATURE section, add state specific fraud warning for NJ
5. SIGNATURE section, add state specific fraud warning for OR
143 (2013/09)
Transportation Section
Please Note: This form is now 3 pages
Page 1
1. Replace ACORD logo
2. Reduce font of title to 14 pt bold
3. Add a field for AGENCY CUSTOMER ID to top right hand corner
4. Replace IDENTIFICATION section with standard section Header. Fields include: AGENCY,
POLICY NUMBER, EFFECTIVE DATE, CARRIER, NAIC CODE and APPLICANT / FIRST
NAMED INSURED.
5. OPERATIONS section, revise text in parentheses in header and bold text
2 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
143 (2013/09)
Transportation Section (continued)
6. Revise VEHICLE SCHEDULE title to all bold
7. GENERAL INFORMATION section, increase height of REMARKS and make a separate
section and add text in parentheses
8. Move MOTOR TRUCK statement from footer into REMARKS section and revise to: MOTOR
TRUCK CARGO LEGAL LIABILITY on Page 2 and add dividing line
9. Add “Attach to ACORD 125” to footer
10. Reformat copyright so that the year is the first character after the copyright symbol.
Revise years to 1991-2013 and add: All rights reserved.
11. Add “The ACORD name and logo are registered marks of ACORD” to footer
Page 2
12. Add a field for AGENCY CUSTOMER ID to top right hand corner
13. Revise VEHICLE SCHEDULE title to all bold
14. GENERAL INFORMATION section, increase height of REMARKS and make a separate
section and add text in parentheses
15. Revise and move “Attach to ACORD 125” into REMARKS section and add dividing line
16. Add Page 2 of 3 to footer
Page 3 (new page)
17. Add a field for AGENCY CUSTOMER ID to top right hand corner
18. Add new SIGNATURE section with fraud warnings
19. Add “Authorized Representative” statement immediately below fraud warnings
20. Add Signature fields
21. Add Page 3 of 3 to footer
144 (2013/09)
Glass and Sign Section
Page 1
1. Revise title of form to Glass and Sign Section
2. Revise statement “ATTACH TO ACORD 140” to “Attach to ACORD 125 and ACORD 140”
immediately above footer
3. Revise copyright years to 1980-2013
Page 2
4. Add text in parentheses in REMARKS section title
Page 3
5. Add text in parentheses in REMARKS section title
6. Add new SIGNATURE section with completely revised fraud warnings
7. Add “Authorized Representative” statement immediately below fraud warnings
8. Add Signature fields
3 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
145 (2013/09)
Accounts Receivable / Valuable Papers
Please Note: This form is now 3 pages
Page 1
1. Replace ACORD logo
2. Reduce font of title to 14 pt bold
3. Add a field for AGENCY CUSTOMER ID to top right hand corner
4. Replace IDENTIFICATION section with standard section Header. Fields include: AGENCY,
POLICY NUMBER, EFFECTIVE DATE, CARRIER, NAIC CODE and APPLICANT / FIRST
NAMED INSURED.
5. All sections, bold all text in parentheses in field labels and revise checkboxes to standard
size
6. GENERAL INFORMATION section, increase height of REMARKS and make a separate
section and add text in parentheses
7. Move VALUABLE PAPERS ON REVERSE SIDE up into Remarks and revise to VALUABLE
PAPERS on Page 2 and add dividing line
8. Add “Attach to ACORD 125” to footer
9. Reformat copyright so that the year is the first character after the copyright symbol.
Revise years to 1980-2013 and add: All rights reserved.
10. Add “The ACORD name and logo are registered marks of ACORD” to footer
Page 2
11. Add a field for AGENCY CUSTOMER ID to top right hand corner
12. All sections, bold all text in parentheses in field labels and revise checkboxes to standard
size
13. LOCATION section, move down PREMISES # and BUILDING # fields to the right of
LOCATION header
14. Add text in parentheses to REMARKS section
15. Revise and move “Attach to ACORD 125” into REMARKS section and add dividing line
16. Add Page 2 of 3 to footer
Page 3 (new page)
17. Add a field for AGENCY CUSTOMER ID to top right hand corner
18. Add new SIGNATURE section with fraud warnings
19. Add “Authorized Representative” statement immediately below fraud warnings
20. Add Signature fields
21. Add Page 3 of 3 to footer
4 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
146 (2013/09)
Equipment Floater Section
Please Note: This form is now 3 pages
Page 1
1. Reduce font of title to 14 pt bold
2. Add a field for AGENCY CUSTOMER ID to top right hand corner
3. Replace IDENTIFICATION section with standard section Header. Fields include: AGENCY,
POLICY NUMBER, EFFECTIVE DATE, CARRIER, NAIC CODE and APPLICANT / FIRST
NAMED INSURED.
4. Increase height of TERRITORY OF OPERATION, TYPE OF OPERATION and COVERAGE /
DEDUCTIBLE sections. Put extra space around slash (/) in header
5. UNSCHEDULED EQUIPMENT section, extend lines dividing the rows
6. Put extra space around slash (/) in header for ADDITIONAL INTEREST / CERTIFICATE
RECIPIENTS
7. GENERAL INFORMATION section, delete border around the Y / N fields
8. GENERAL INFORMATION section, put extra spaces around slashes in Question 1
9. Delete “Page 1 of 2” and add “Attach to ACORD 125” to footer
10. Reformat copyright so that the year is the first character after the copyright symbol.
Revise years to 1988-2013 and add: All rights reserved.
Page 2
11. Add a field for AGENCY CUSTOMER ID to top right hand corner
12. Move % COINSURANCE field to the left
13. Delete ATTACH TO ACORD 125 and add Page 2 of 3 to footer
Page 3 (new page)
14. Add a field for AGENCY CUSTOMER ID to top right hand corner
15. Add new SIGNATURE section with fraud warnings
16. Add “Authorized Representative” statement immediately below fraud warnings
17. Add Signature fields
18. Add Page 3 of 3 to footer
5 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
147 (2013/09)
Installation / Builders Risk
Please Note: This form is now 3 pages
Page 1
1. Replace ACORD logo
2. Delete border around title
3. Center title and reduce font to 14 point. Add extra spaces around slash (/) in title
4. Add field for AGENCY CUSTOMER ID to top right corner
5. Replace IDENTIFICATION section with standard section header. Fields include: AGENCY,
POLICY NUMBER, EFFECTIVE DATE, CARRIER, NAIC CODE and APPLICANT / FIRST
NAMED INSURED. Retain checkboxes for INSTALLATION and BUILDERS RISK from
prior IDENTIFICATION section.
6. RECEIPTS section, bold text in parentheses in NEXT 12 MONTHS column label
7. JOBS / VALUES section, add extra spaces around slash (/) in title
8. JOBS / VALUES section, bold text in parentheses in MATERIAL COST column label
9. JOBS / VALUES section, reduce height of rows
10. Replace ADDITIONAL INTEREST section with standard format and add a checkbox next
to section header labeled ACORD 45 ATTACHED. Delete one Additional Interest group.
11. TRANSPORTATION / SECURITY section, add extra spaces around slash (/) in title
12. TRANSPORTATION / SECURITY section, move percent symbol to the left and bold
13. Expand height of REMARKS section, make a separate section and add text in parentheses
14. Move SPECIFIC JOB statement from footer into REMARKS section and revise to:
SPECIFIC JOB on Page 2 and add dividing line
15. Add “Attach to ACORD 125” to footer
16. Reformat copyright so that the year is the first character after the copyright symbol.
Revise years to 2001-2013 and add: All rights reserved.
17. Add “The ACORD name and logo are registered marks of ACORD to footer
Page 2
18. Add field for AGENCY CUSTOMER ID to top right corner
19. JOB TERM / VALUES section, add extra spaces around slash (/) in title
20. JOB DESCRIPTION section, Move up INSURED’S JOB NUMBER: field
21. Replace ADDITIONAL INTEREST section with standard format and add a checkbox next
to section header labeled ACORD 45 ATTACHED. Delete one Additional Interest group.
22. REMARKS section, make a separate section and add text in parentheses
23. Move statement from footer into REMARKS section and revise to: “Attach to ACORD 125”
and add dividing line
24. Add Page 2 of 3 to footer
Page 3 (new page)
25. Add field for AGENCY CUSTOMER ID to top right corner
26. Add new SIGNATURE section with fraud warnings
27. Add “Authorized Representative” statement immediately below fraud warnings
28. Add Signature fields
29. Add Page 3 of 3 to footer
6 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
148 (2013/09)
Electronic Data Processing Section
Please Note: This form is now 3 pages
Page 1
1. Replace ACORD logo
2. Delete border around title
3. Center title and reduce font to 14 point.
4. Add field for AGENCY CUSTOMER ID to top right corner
5. Revise DATE format
6. Replace IDENTIFICATION section with standard section header. Fields include: AGENCY,
POLICY NUMBER, EFFECTIVE DATE, CARRIER, NAIC CODE and APPLICANT / FIRST
NAMED INSURED.
7. PREMISES INFORMATION section, add extra spaces around slash (/) in two MEDIA /
DATA labels in the Subject of Insurance column
8. PREMISES INFORMATION section, in FLOOD COVERAGE and EARTHQUAKE COVERAGE
groups, reformat ZONE: label to expand filed sizes
9. SCHEDULE OF EQUIPMENT section, reduce height of rows
10. Expand height of REMARKS section and add text in parentheses
11. Revise “Please complete reverse side” to: “Attach to ACORD 125” in footer
12. Reformat copyright so that the year is the first character after the copyright symbol.
Revise years to 1991-2013 and add: All rights reserved.
13. Add “The ACORD name and logo are registered marks of ACORD to footer
Page 2
14. Add field for AGENCY CUSTOMER ID to top right corner
15. COMPUTER ROOM INFORMATION section, move YES / NO checkboxes on the right hand
side of the section all the way to the right hand border
16. GENERAL INFORMATION section, move YES / NO checkboxes on the right hand side of
the section all the way to the right hand border
17. Replace ADDITIONAL INTEREST section with standard format and add a checkbox next
to section header labeled ACORD 45 ATTACHED.
18. Expand height of REMARKS section and add text in parentheses
19. Delete “Attach to Applicant Section” and add: “Page 2 of 3” in footer
Page 3 (new page)
20. Add field for AGENCY CUSTOMER ID to top right corner
21. Add new SIGNATURE section with fraud warnings
22. Add “Authorized Representative” statement immediately below fraud warnings
23. Add Signature fields
24. Add Page 3 of 3 to footer
7 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
190 (2013/09)
Supplemental Property Application
Page 3
1. Reduce height of REMARKS section
2. STATEMENT / SIGNATURE section, delete first paragraph and revise all remaining fraud
warnings. Use state abbreviations in all paragraph titles
3. STATEMENT / SIGNATURE section, add fraud warning for KY, NY, OH and PA
4. STATEMENT / SIGNATURE section, add state specific fraud warning for NJ
5. STATEMENT / SIGNATURE section, add state specific fraud warning for OR
196 (2013/09)
Medical Professional Liability Insurance Application
Page 3
1. Reduce height of REMARKS section
2. SIGNATURE section, delete first paragraph and revise all remaining fraud warnings. Use
state abbreviations in all paragraph titles
3. SIGNATURE section, add fraud warning for KY, NY, OH and PA
4. SIGNATURE section, add state specific fraud warning for NJ
5. SIGNATURE section, add state specific fraud warning for OR
401 (2013/09)
Agriculture Application
Applicant Information Section
Page 4 (SIGNATURE Section)
1. Use state abbreviations for all “Applicable in” headers
2. Delete first paragraph and revise all remaining fraud warnings
3. Add fraud warning for KY, NY, OH and PA
4. Add state specific fraud warning for NJ
5. Add state specific fraud warning for OR
410 (2013/09)
Small Farm / Ranch Application
Page 5 (SIGNATURE Section)
1. Use state abbreviations for all “Applicable in” headers
2. Delete first paragraph and revise all remaining fraud warnings
3. Add fraud warning for KY, NY, OH and PA
4. Add state specific fraud warning for NJ
5. Add state specific fraud warning for OR
8 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
825 (2013/09)
Professional / Specialty Insurance Application
(For Use in Management, Executive & Professional Lines – Applicant Section)
Page 4
1. Reduce height of REMARKS section
2. SIGNATURE section, delete first paragraph and revise all remaining fraud warnings. Use
state abbreviations in all paragraph titles
3. SIGNATURE section, add fraud warning for KY, NY, OH and PA
4. SIGNATURE section, add state specific fraud warning for NJ
5. SIGNATURE section, add state specific fraud warning for OR
9 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
State Specific – Revised
132 NJ (2013/07)
New Jersey Workers Compensation Insurance Plan
Instructions and Rules
Page 1
1. Revise the ACORD copyright in the footer so the years are the first item after the
copyright symbol and add “All rights reserved.” Revise copyright years to 1996-2013
2. Add “The ACORD name and logo are registered marks of ACORD” to footer
Page 3
3. Item 9, delete the word OFFERED/ from the title
4. Item 9, delete the first sentence and the last underlined sentence and reformat remaining
text
133 NJ (2013/07)
New Jersey Workers Compensation Insurance Plan
Application for Designation of an Insurance Company
Page 1
1. Revise copyright years to 1996-2013
Page 2
2. Item 9, delete the word OFFERED/ from the title
3. Item 9, delete the last sentence beginning with the word Also
4. Item 9, delete the YES / NO checkboxes and the IF YES, etc. statement
5. Item 9, delete the statement below the table
6. Increase height of item 10, NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
section
10 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
137 AR (2013/10)
Arkansas Commercial Auto, Coverages / Limits Section
Page 1
1. BUSINESS AUTO SECTION, add a MEDICAL PAYMENTS row with checkboxes and limit
each person field, in the second blank row on left
2. BUSINESS AUTO SECTION, increase height of UNINSURED MOTORIST row and
decrease height of UNDERINSURED MOTORIST row
3. Revise text in parentheses in ENDORSEMENTS / REMARKS section title and reduce height
of entire section
4. SIGNATURE section, revise Notice of Insurance Information Practices and Fraud Warning
5. Revise ACORD copyright to 1996-2013
6. Add “Attach to ACORD 127 and/or 132” to footer immediately below the page numbers
Page 2
7. TRUCKERS SECTION, add a MEDICAL PAYMENTS row with checkboxes and limit each
person field, in the second blank row on left
8. TRUCKERS SECTION, increase height of UNINSURED MOTORIST row and decrease
height of UNDERINSURED MOTORIST row
9. Revise text in parentheses in ENDORSEMENTS / REMARKS section title and reduce height
of entire section
10. SIGNATURE section, revise Notice of Insurance Information Practices and Fraud Warning
11.
Page 3
12. MOTOR CARRIER SECTION, add a MEDICAL PAYMENTS row with checkboxes and limit
each person field, in the second blank row on left
13. MOTOR CARRIER SECTION, increase height of UNINSURED MOTORIST row and
decrease height of UNDERINSURED MOTORIST row
14. Revise text in parentheses in ENDORSEMENTS / REMARKS section title and reduce height
of entire section
15. SIGNATURE section, revise Notice of Insurance Information Practices and Fraud Warning
11 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
854 CA (2013/07)
California FAIR Plan Property Insurance
Application for Dwelling Insurance
Page 1 of Application
1. IMPORTANT – PLEASE READ informational text at the top of the form, second paragraph,
delete “and the applicant’s representative”
2. Delete BROKER INFORMATION section, and move up LOCATION OF PROPERTY TO BE
INSURED section in its place
3. Redesign DEDUCTIBLE REQUESTED section and add a dividing line between deductible
amounts checkboxes and the Inflation Guard Declination checkbox
4. Add “The ACORD name and logo are registered marks of ACORD” to footer
Page 2 of Application
5. Revise PUBLIC PROTECTION CLASS QUESTIONNAIRE section header to FIRE
PROTECTION INFORMATION
6. FIRE PROTECTION INFORMATION section, delete fields labeled Protection Class (if
known) and Fire District. Reformat remaining fields.
7. CERTIFICATION section, delete first sentence and revise second sentence to: I have
examined the entire application and provided the required information, which is correct to
the best of my knowledge.
8. CERTIFICATION section, second paragraph, delete “(or, if the broker, that I made the
applicant aware)”
9. CERTIFICATION section, delete “Broker or” from the Signature line label
12 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
855 CA (2013/07)
California FAIR Plan Property Insurance
Application for Commercial Insurance
Page 1 of Application
1. IMPORTANT – PLEASE READ informational text at the top of the form, second paragraph,
delete “and the applicant’s representative”
2. Delete BROKER INFORMATION section, and move up LOCATION OF PROPERTY TO BE
INSURED section in its place
3. COVERAGE AND RATING INFORMATION section, expand height of BUILDING
OCCUPIED AS field
4. Add “The ACORD name and logo are registered marks of ACORD” to footer
Page 2 of Application
5. Revise PUBLIC PROTECTION CLASS QUESTIONNAIRE section header to FIRE
PROTECTION INFORMATION
6. FIRE PROTECTION INFORMATION section, delete fields labeled Current Protection Class
(if known), District and Class fields. Redesign section to contain same fields as on the 854
CA form. Fields include: Responding fire station (city or county), Is the property inside the
City Limits? Yes / No checkboxes, APN:, Latitude, Longitude, Estimated number of miles
from the fire station and Estimated distance from public fire hydrant
7. BRUSH / WILDFIRE INFORMATION section, delete “Broker or” from the Signature line
label
8. CERTIFICATION section, delete first sentence and revise second sentence to: I have
examined the entire application and provided the required information, which is correct to
the best of my knowledge.
9. CERTIFICATION section, second paragraph, delete “(or, if the broker, that I made the
applicant aware)”
10. CERTIFICATION section, delete “Broker or” from the Signature line label
13 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
Countrywide – New
NONE
State Specific – New
NONE
WITHDRAWN FORMS
861 FL (2013/01)
Florida Auto Supplement
Notification of Personal Injury Protection Benefits
It is the position of the Florida Office of Insurance Regulation that Rule 69O-176.013 of the
Florida Administrative Code allows insurers to only utilize Florida form OIR-B1-1149 to comply with
personal injury protection notification requirements. Although ACORD 861 FL mirrors Florida form
OIR-B1-1149 and was developed to be used as a tool so that insurers may comply with the
requirements found in Florida law, the Florida Office of Insurance Regulation has requested that
ACORD withdraw ACORD 861 FL from use.
FIG REVISION ONLY
24 (2009/09)
Certificate of Property Insurance
1. Revise FIG text for the Title row field description
35 (2011/09)
Cancellation Request / Policy Release
1. Revise FIG text for the Producer’s Signature field to:
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) completing this form.
14 of 15 ACORD Explanation of Changes 06-28-2013

Explanation of Changes 06-28-2013
LIFE / ANNUITY / HEALTH FORMS
Countrywide – Revised
NONE
State Specific - Revised
NONE
Countrywide – New
NONE
State Specific – New
NONE
WITHDRAWN FORMS
NONE
15 of 15 ACORD Explanation of Changes 06-28-2013