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Oregon Mutual Agency Forms Library
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The items with hyperlinks listed below are available in PDF format by clicking on the link. Unlisted forms must be requested through your Underwriter. Forms are in alphabetical order by section. Brochures can be viewed by clicking on the link, printed copies may be ordered from the Supply Department. Click here to view Sample Contract Forms. Notes on PDF Files: For full functionality of the forms you select we recommend using Adobe Acrobat 7.0 or higher. To download the latest version of Adobe Acrobat Reader go to: http://www.adobe.com/products/acrobat/readstep2.html. |
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| Form Number | Revision Date |
Form Title |
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PERSONAL LINES |
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AUTOMOBILE |
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| M1236AO | 09-16 | Acceptance of Coverage Limitations for Unlisted Drivers - Oregon | |
| G1126A | 04-99 | Automobile Inspection | |
| M0029AI | 01-19 | Idaho Custom Shield Uninsured Motorist and Underinsured Motorist Disclosure Statement | |
| M1223A | 04-17 |
Lapse in Prior Coverage Eligibility Statement |
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| G0027A | 10-10 |
Liability Insurance ID Card - Temporary - Valid for 45 Days Only - Oregon, Washington, Idaho |
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| M0228AC | 10-10 |
Liability Insurance ID Card - Temporary - Valid for 45 Days Only - California |
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| M0734A | 01-01 |
Named Driver Exclusion Endorsement - California |
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| G0566AO | 10-02 |
Named Driver Exclusion Endorsement - Oregon |
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| G0565A | 10-02 |
Named Driver Exclusion Endorsement - Idaho |
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| G0565A | 10-14 |
Named Driver Exclusion Endorsement - Washington |
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| M1706AC | 11-02 | Personal Auto Accident Record Declaration - California | |
| ACORD 90 CA | 01-00 | Personal Auto Application - California | |
| ACORD 90 ID |
03-01 |
Personal Auto Application - Idaho | |
| G1090AO | 04-14 | Personal Auto Application - Oregon - Custom Shield Auto | |
| ACORD 90 WA | 08-00 | Personal Auto Application - Washington | |
| M1120A | 11-18 | Physicians Report for Automobile Insurance | |
| G0096AI | 01-09 |
Rejection of Medical Coverage - Idaho |
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| G1006A | 08-05 | Senior Driver Questionnaire | |
| M0039A | 03-16 | Statement Electing Lower Limits For Uninsured Motorist Coverage - Oregon | |
| G0008AW | 12-16 | Statement Electing Lower Limits For Underinsured Motorist Coverage - Washington | |
| M1710AC | 12-08 | Uninsured Motorist Reduction - BI & PD - California | |
| G1224A | 08-05 | Young Driver Questionnaire | |
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PROPERTY |
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| M1117C | 07-11 | California Residential Property Insurance Disclosure - Dwelling Fire Only | |
| M1118C | 07-20 | California Residential Property Insurance Disclosure - Homeowners Only | |
| ACORD 84 | 12-04 | Dwelling Fire Application | |
| ACORD 80 | 12-04 | Homeowner Application | |
| ACORD 85 | 09-04 | Mobile Home Application - Oregon, Washington, Idaho | |
| G1004H | 11-15 | Modernization Questionnaire | |
| M1262 | 08-16 | PC 9 & 10 Fire Suppression Adequacy Questionnaire | |
| G0022HC | 03-03 | Personal Liability & Medical Payments Coverage - Section II - Liability Coverage - California | |
| G0022HI | 05-03 | Personal Liability & Medical Payments Coverage - Section II - Liability Coverage - Idaho | |
| G0022HO | 03-03 | Personal Liability & Medical Payments Coverage - Section II - Liability Coverage - Oregon | |
| G0022HW | 03-03 | Personal Liability & Medical Payments Coverage - Section II - Liability Coverage - Washington | |
| ACORD 82 | 03-04 | Watercraft Application | |
| M3036 | 07-21 | Wildfire Supplemental | |
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PERSONAL LINES BROCHURES - INSERTS - FLYERS (order printed copies from supply@ormutual.com) |
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| M1250AO | 02-19 | Auto Protection Product Description - Oregon | |
| M1260AW | 02-19 | Auto Protection Product Description - Washington | |
| M1253AI | 02-19 | Auto Protection Product Description - Idaho | |
| M1230A | 10-20 | Auto Reference Guide - Oregon, Washington, Idaho | |
| M1233AC | 01-19 | Auto Reference Guide - California | |
| M1281A | 05-19 | Automobile Member Facing Flyer | |
| M1282A | 12-20 | Why Oregon Mutual Personal Auto Member Facing Flyer | |
| M1246H | 02-16 | HO-5 Company Comparison - Oregon & Idaho | |
| M1102H | 03-20 | Homeowner Form 3 & 5 Coverage Comparison - Oregon, Washington, Idaho | |
| M1103HC | 03-20 | Homeowner Form 3 & 5 Coverage Comparison - California | |
| M1277H | 05-19 | Homeowners Member Facing Flyer | |
| M1413H | 03-19 | Home Systems Protection Coverage Flyer | |
| M1410H | 03-19 | Inland Flood Coverage Endorsement Agent Facing Flyer | |
| M1411H | 03-19 | Inland Flood Coverage Endorsement Member Facing Flyer | |
| M1266 | 04-17 | Personal Lines Property Options Flyer | |
| M1268 | 06-20 | Personal Lines Newsletter 2020 - Wildfire Preparedness | |
| M1267 | 04-17 | Personal Lines Auto Options Flyer | |
| G1220H | 02-07 | Personal Property Inventory Record (Available in PDF format only) | |
| M1225 | 12-20 | Property Reference Guide - Oregon, Washington, Idaho | |
| M1228C | 12-20 | Property Reference Guide - California | |
| M1065 | 05-19 | Renters Member Facing Flyer | |
| M1263A | 01-20 | Roadside Assistance & Towing Services Member Facing Flyer | |
| M1425H | 01-21 | Service Line Member Facing Flyer | |
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COMMERCIAL LINES |
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| ACORD 145 | 03-04 | Accounts Receivable/Valuable Papers | |
| M3257 | 05-12 | Agent Review of Insured's Coverages & Limits Certification | |
| M3249 | 11-18 | Agent's Binding Authority - Commercial Lines | |
| ACORD 36 | 01-07 | Agent/Broker of Record Change | |
| M3023 | 04-17 | Apartment/Condominium/Rental Dwelling Questionnaire | |
| M3001F | 05-89 | Application for Limited Farm Pollution | |
| M3020B | 02-20 | Application for Pizza / Restaurant Delivery - Employer's Non-Owned Auto Liability | |
| M3016A | 01-14 | Auto Repair - Service Station Questionnaire | |
| ACORD 127 | 05-10 | Business Auto Section | |
| M3012M | 01-02 | Business Mini-Computer Coverage App. | |
| ACORD 160 | 10-11 | Business Owners Application | |
| ACORD 161 | 11-98 | Business Owners Supplemental Application | |
| M3116C | 01-21 | California Residential Property Ins. Disclosure | |
| ACORD 35 | 09-11 | Cancellation Request/Policy Release | |
| ACORD 25 | 05-10 | Certificate of Liability Insurance | |
| M3306 | 10-10 | Certification of Coverages/Limits by Agent | |
| ACORD 137 CA | 12-10 | Commercial Auto Application - California | |
| ACORD 137 ID | 07-11 | Commercial Auto Application - Idaho | |
| ACORD 137 OR | 04-11 | Commercial Auto Application - Oregon | |
| ACORD 137 WA | 08-11 | Commercial Auto Application - Washington | |
| M3143A | 03-12 | Commercial Auto Supplemental Application | |
| ACORD 126 | 09-11 | Commercial General Liability Section | |
| ACORD 125 | 09-11 | Commercial Insurance Application | |
| M3037 | 10-23 | Commercial Older Building Supplemental | |
| ACORD 175 | 03-11 | Commercial Policy Change Request | |
| M3010 | 07-93 | Commercial Policy Endorsement Request / Acknowledgement of Commercial Policy Change | |
| M3000L | 11-13 | Contractors Supplemental Application | |
| ACORD 141 | 10-11 | Crime Section 2000 | |
| M3027 | 04-15 | Data Compromise Increased Limits Questionnaire | |
| M3302A | 09-05 | Dealer's Reporting Form | |
| M8757C | 06-19 | Designating an Individual to Receive Notice of Lapse or Cancellation for Nonpayment of Premium | |
| M3009 | 01-14 | Earthquake Questionnaire | |
| M3029 | 12-15 | Employment Practices Liability Insurance Supplemental Application | |
| M3030 | 02-18 | Employment Practices Liability Insurance Supplemental Application For $250,000 | |
| M3149 | 04-16 | Employment Related Practices Liability Insurance Coverage (Stuffer) | |
| ACORD 28 | 12-09 | Evidence of Commercial Property Insurance | |
| ACORD 27 | 12-09 | Evidence of Property Insurance | |
| ACORD 146 | 02-07 | Equipment Floater Section | |
| ACORD 401 | 09-07 | (FAR) Agriculture Application - Applicant Information Section | |
| ACORD 404 | 09-07 | (FAR) Agriculture Liability Section | |
| ACORD 405 | 09-07 | (FAR) Agriculture Premises / Location Diagram | |
| ACORD 402 | 09-07 | (FAR) Agriculture Property Section | |
| ACORD 403 | 09-07 | (FAR) Agriculture Property Section - Scheduled & Unscheduled Farm Personal Property | |
| ACORD 406 | 09-07 | (FAR) Agriculture Supplement - Unscheduled Farm Personal Property Inventory Form | |
| ACORD 408 | 09-07 | (FAR) Equine Liability Supplement | |
| M3019 | 04-19 | (FAR) Farm/Agribusiness/Ranch Questionnaire | |
| ACORD 407 | 12-09 | (FAR) Livestock Mortality Section | |
| ACORD 410 | 04-04 | (FAR) Small Farm/Ranch Application | |
| M3026 | 10-23 | Farm Property Modernization Questionnaire | |
| M3003F | 05-89 | Field Grain Application | |
| ACORD 128 | 05-08 | Garage and Dealers Section | |
| ACORD 3 | 02-10 | General Liability Notice of Occurrence/Claim | |
| ACORD 144 | 10-11 | Glass and Sign Supplement | |
| ACORD 147 | 02-01 | Installation/Builders Risk Section | |
| ACORD 75 | 04-10 | Insurance Binder | |
| M3211 | 08-93 | Lost Policy Certificate and Release | |
| M3025 | 01-14 | Machine Shop Supplemental Application | |
| M3125 | 12-20 | Policyholder Disclosure Notice of Terrorism Insurance Coverage | |
| M2784 | 12-20 | Policyholder Disclosure Notification - Intent to Exclude Terrorism | |
| ACORD 140 | 10-11 | Property Section | |
| M3015B | 01-18 | Restaurant Supplemental Application (for attachment to Businessowner Applications) | |
| M3118AO | 07-94 | Statement Electing Lower Limits For Uninsured Motorists Coverage | |
| ACORD 143 | 01-04 | Transportation Section | |
| M3031 | 01-19 | Trucking Questionnaire | |
| ACORD 131 | 11-11 | Umbrella Section | |
| M3247B | 07-22 | Underwriting Guidelines for Apartment & Residential Condominium Associations | |
| M3507 | 01-20 | Underwriting Guidelines for Car Wash (Effective 1-20) | |
| M3238 | 09-15 | Underwriting Guidelines for Contractors (Effective 9-1-15) | |
| M3272B | 09-14 | Underwriting Guidelines for Motels and Hotels, Including Resorts | |
| M3239 | 05-22 | Underwriting Guidelines for Restaurants | |
| M3250B | 02-20 | Underwriting Guidelines for Restaurant & Pizza Delivery | |
| M3254B | 09-07 | Underwriting Guidelines for Tow Trucks | |
| M3255B | 02-20 | Underwriting Guidelines for Dump Trucks | |
| M3256B | 02-20 | Underwriting Guidelines for Concrete Mixed in Transit | |
| M0029AI | 02-09 | Idaho Uninsured Motorist and Underinsured Motorist Disclosure Statement | |
| ACORD 23 | 05-10 | Vehicle or Equipment Certificate of Insurance | |
| ACORD 129 | 11-09 | Vehicle Schedule | |
| M3018 | 01-04 | Veterinarians Liability Insurance Application | |
| IL U 052 | 10-10 | Washington Personal Injury Protection Coverage Selection/Rejection | |
| IL U 008 | 04-06 | Washington Underinsured Motorists Coverage Selection/Rejection | |
| M3036 | 07-21 | Wildfire Supplemental | |
| M3013 | 04-15 | Winery Questionnaire | |
| M3022 | 07-09 | Woodburning Appliance Questionnaire | |
| M3148 | 12-15 | Workers Compensation Waiver of Our Rights to Recover and Indemnity Agreement | |
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COMMERCIAL LINES BROCHURES - INSERTS - FLYERS (order printed copies from supply@ormutual.com) |
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| M3513 | 06-21 | 10 Tips for Cyber Security Flyer | |
| M3245B | 06-19 | Apartment Owner Member Facing Flyer | |
| M3295B | 07-22 | Apartments Agent Facing Flyer | |
| M3223B | 09-19 | Auto Repair Member Facing Flyer | |
| M3299B | 08-19 | Auto Services Agent Facing Flyer | M3473B | 08-20 | BOP Cluster Comparison |
| M3215B | 06-19 | Businessowner Member Facing Flyer | |
| M3286 | 03-24 | Commercial Appetite Guide | |
| M3500A | 08-19 | Commercial Auto Agent Facing Flyer | |
| M3281A | 02-20 | Commercial Auto Cluster Overview Flyer | |
| M3268 | 01-23 | Commercial Hit List Flyer | |
| M3228 | 03-24 | Commercial Lines Generally Acceptable Classes - November 2018 | |
| M3278P | 12-17 | Commercial Property Cluster Overview Flyer | |
| M3279P | 12-17 | Commercial Property Special Cluster Overview Flyer | |
| M3291B | 06-19 | Condo Associations Member Facing Flyer | |
| M3294 | 03-24 | Contractors Agent Facing Flyer | |
| M8746 | 03-19 | CyberOne Insurance Flyer | |
| M8747 | 03-19 | Data Compromise & CyberOne Fact Sheet Flyer | |
| M3514 | 06-21 | Cyber Password Hack Inforgraphic Tips Flyer | |
| M3511 | 06-21 | Cyber Risk Management Portal Access Flyer | |
| M3154 | 06-21 | EPLI - Legal Advice Line Flyer | |
| M3515 | 06-21 | Equipment Breakdown 10 Reasons Flyer | |
| M3293F | 08-19 | Farm & Ranch Agent Facing Flyer | |
| M3244F | 05-19 | Farm / Ag / Ranch Member Facing Flyer | |
| M3275F | 04-20 | Farm Personal Cluster Summary Flyer | |
| M3276F | 04-20 | Farm Commercial Cluster Summary Flyer | |
| M3282L | 12-17 | General Liability Cluster Overview Flyer | |
| M3297B | 09-19 | Hobby Farms Agent Facing Flyer | |
| M3230B | 06-19 | Hotel & Motels Member Facing Flyer | |
| M3501B | 10-19 | Lessors Risk Agent Facing Flyer | |
| M3502B | 10-19 | Manufacturing Agent Facing Flyer | |
| M3504B | 10-19 | Office Agent Facing Flyer | |
| M3505B | 11-19 | Office Member Facing Flyer | |
| M3280 | 10-18 | OnPoint 4th Quarter 2018 Suggested Classes - Commercial Lines Flyer | |
| M3277F | 12-17 | Orchard & Vineyard Growers Endorsement Summary Flyer | |
| M3506B | 03-24 | Rental Dwellings Agent Facing Flyer | |
| M3289B | 05-19 | Restaurant Agent Facing Flyer | |
| M3226B | 05-19 | Restaurant Member Facing Flyer | |
| M3231B | 08-19 | Retail Agent Facing Flyer | |
| M1263A | 01-20 | Roadside Assistance & Towing Services Member Facing Flyer | |
| M3503B | 10-19 | Service Oriented Agent Facing Flyer | |
| M3283 | 12-17 | Small Animal Services Cluster Overview Flyer | |
| M3512 | 06-21 | Top 10 Reasons for Cyber Coverage Flyer | |
| M3229B | 07-19 | Veterinarian Coverage Member Facing Flyer | |
| M3285 | 12-17 | Veterinarians Large Animal Cluster Overview Flyer | |
| M3284 | 12-17 | Veterinarians Small Animal Cluster Overview Flyer | |
| M3298B | 08-19 | Veterinary Agent Facing Flyer | |
| M3287 | 03-19 | Vintner Insurance Protection Endorsement Coverage Descriptions | |
| M3288 | 03-19 | Vintner Insurance Protection VIP Endorsement Limits (Bronze Medal, Silver Medal, Gold Medal) Agent Facing Flyer | |
| M3290 | 05-19 | Winery & Vintner Agent Facing Flyer | |
| M3265 | 05-19 | Winery & Vintner Insurance Protection Member Facing Flyer | |
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MISCELLANEOUS |
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| M9409 | 07-18 | Agency Download Set-Up Information | |
| M9254 | 07-18 | Agency Management Codes/OMI Unique Coverage Codes | |
| M9258 | 01-24 | Agent Contingency Bonus Program - Effective 1-1-2024 | |
| G6026 | 09-19 | Authorization for Automatic Debit - Policyholder Electronic Funds Transfer Plan | |
| M6038 | 04-17 | BizLink Direct Debit Authorization (Agency Sweep) Agent Use Only | |
| G6039 | 08-02 | BizLink NSF Check Return Agent Use Only | |
| M8806B | 08-20 | Notice to Policyholder - Businessowners | |
| M8807 | 04-20 | Business Interruption Advisory Notice - CPP | |
| M8808 | 04-20 | Business Interruption Advisory Notice - No Cluster | |
| M8809 | 04-20 | Business Interruption Advisory Notice - With Xtreme Cluster | |
| M8810 | 04-20 | Business Interruption Advisory Notice - Member Cover Letter | |
| M8821B | 09-21 | Businessowners Advisory Notice to Policyholders - Oregon, Washington, Idaho | |
| M8821B | 11-21 | Businessowners Advisory Notice to Policyholders - California | |
| M8810 | 04-20 | Business Interruption Advisory Notice - Member Cover Letter | |
| M8825B | 01-23 | Businessowners Advisory Notice To Policyholders | |
| M8826BC | 05-23 | Businessowners Advisory Notice To Policyholders | |
| M8829BC | 05-24 | Businessowners Advisory Notice To Policyholders | |
| M9135 | 07-19 | Claims Member Facing Flyer | |
| M9143C12 | 08-19 | Commission Schedule - Personal Lines - Effective 8-1-19 - California | |
| M9108I14 | 02-24 | Commission Schedule - Personal Lines - Effective 2-1-24 - Idaho | |
| M9199O12 | 08-19 | Commission Schedule - Personal Lines - Effective 8-1-19 - Oregon | |
| M9105W12 | 08-19 | Commission Schedule - Personal Lines - Effective 8-1-19 - Washington | |
| M9139C | 04-15 | Commission Schedule - Commercial Lines - Effective 4-1-15 - California | |
| M9138I | 04-15 | Commission Schedule - Commercial Lines - Effective 4-1-15 - Idaho | |
| M9136O | 04-15 | Commission Schedule - Commercial Lines - Effective 4-1-15 - Oregon | |
| M9137W | 04-15 | Commission Schedule - Commercial Lines - Effective 4-1-15 - Washington | |
| M1185C | 06-18 | Consumer Report Disclosure - California - Homeowners | |
| M1185C | 04-17 | Consumer Report Disclosure - California - Auto | |
| M1274C | 04-17 | Consumer Report Disclosure - California | |
| G1197I | 06-18 |
Consumer Report Disclosure - Homeowners - Idaho |
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| G1197I | 04-17 |
Consumer Report Disclosure - Auto - Idaho |
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| G1219AI | 04-17 |
Consumer Report Disclosure - Idaho |
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| G1091O | 04-17 |
Consumer Report Disclosure - Oregon |
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| G1217AO | 04-17 |
Consumer Report Disclosure - Oregon |
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| G1096W | 04-17 |
Consumer Report Disclosure - Washington |
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| G1218AW | 04-17 |
Consumer Report Disclosure - Washington |
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| M9046 | 04-22 | Customer Service Hours & Services Overview | |
| M6045 | 04-17 | Direct Commission Deposit Authorization Agreement | |
| M9134 | 06-22 | Document Retention Agreement & Guidelines | |
| ACORD 75 | 04-10 | Insurance Binder | |
| G0163 | 03-20 | Member Portal Agreement | |
| M9246 | 03-20 | Member Portal Setup Instructions | |
| M1083 | 10-02 | New Business Payment Plan Eligibility Request - California | |
| G1047 | 11-02 | No Loss Statement | |
| G0162 | 08-19 | Notice of Privacy Policy | |
| M6059 | 03-23 | Payment Options & Down Payment Chart | |
| M9284 | 10-23 | Proxy Solicited on Behalf of the Board of Directors | |
| M1412 | 05-19 | Why Oregon Mutual Insurance | |
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ENVELOPES (order from Supply Dept.) |
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| G9703 | McMinnville Billing Self-Addressed Envelope | ||
| M9633 | McMinnville OMI Insured Policy Envelope | ||
| M9625 | McMinnville Office, Large Self-Addressed Envelope | ||
| M9613 | McMinnville Office, #11 Self-Addressed Envelope | ||
| Order Forms | Sample Contract Forms | |
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