| Application Form Number | For Use In: |
| ICC15 A-2001.1 dated 11.19.15 | AK, AL, AR, AZ, CO, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, TN, TX, UT, VA, VT, WA, WI, WV, WY |
| 15 A-2001.1 dated 11.19.15 | CA, DC, DE, FL, ND, SD |
| CT15 A-2001.1 dated 11.19.15 | CT only |