ACORD 137 InstructionsACORD 137 - GenericCommercial Auto, Coverages/Limits Section Use ACORD 137 to collect the coverage, limits and premium information necessary to write Business Auto, Truckers, or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
Agency name. Applicant (First Name Insured)
Full name of the applicant as it should appear on the policy. The First Named
Insured is given certain rights and responsibilities by the policy contract
language. If more than one insured is named, be sure the one intended to receive
these rights and responsibilities is named first and any additional insureds
identified as such. If joint ownership, the name used may include both names
(e.g., John and Mary Smith). BUSINESS AUTO Coverages Place an "X" in the appropriate Covered auto symbols box(es) for each coverage desired. Additional information on the coverages may be found below.
Business Auto
policies use numeric symbols on the policy declarations to indicate the type(s)
of vehicles for which coverage is in effect. Be sure to place an X in the appropriate
box for each type of coverage. Only those symbols specified for a coverage may
be used. Limits For each coverage
enter the limits as they are to appear on the declarations page. Liability Indicate if the
Limit is based on a Combined Single Limit format or Split Limit format by checking
either the "CSL" or "BI Ea Per" (Bodily Injury Each Person)
box respectively. For CSL complete the first Limit field. For Split Limits complete
the BI Each Person BI each accident and Property Damage Limits. Medical Payments The desired Per
Person Limit. Uninsured Motorists Enter the appropriate
limit(s) following the Liability Format. Hired/Borrowed Liability Enter state(s),
if any, in which autos are Hired or Borrowed Cost of Hire Enter the total
estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is
minimal, check the "If Any" box. The actual exposure will be determined
at time of audit. Non-Owned Liability Enter state(s)
where employees use their own autos in the operations of the applicant's business. Group Type For Non-Owned
liability, "X" all applicable group types of. Employees, Partners
or Volunteer. For each group type indicated list the number of individuals involved. Blank Area Write in additional
coverages desired, their coverage auto symbols and limits in the available boxes.
Use the endorsements section if necessary. Physical Damage This section collects the coverage auto symbols for physical damage coverages. Information on deductible and valuation types is collected elsewhere within the individual Vehicle Description sections. Available coverage options are:
Towing & Labor This coverage
is applicable only to private passenger autos. Comprehensive Check the applicable
box(es). Specified Causes of Loss The Specified Cause of Loss Codes are:
Enter the deductible
only if it is applicable to all vehicles. Collision Enter the deductible
only if it is applicable to all vehicles. Hired Physical Damage Indicate the
states for which coverage is to apply. Enter the estimated number of days and
number of vehicles involved. Coverage/Deductible Check the applicable
coverage(s) and enter the appropriate deductible amount of liability. Coverage is: Indicate if this
coverage is on a primary or secondary basis by checking the appropriate box. TRUCKER Coverages Place an "X" in the appropriate Covered auto symbols box(es) for each coverage desired. Additional information on the coverages may be found below.
Truckers and
Motor Carrier policies use numeric symbols on the policy declarations to indicate
the type(s) of vehicles for which coverage is in effect. Be sure to place an
X in the appropriate box for each type of coverage. Only those symbols specified
for a coverage may be used. Limits For each coverage
enter the limits as they are to appear on the declarations page. Liability Indicate if the
Limit is based on a Combined Single Limit format or Split Limit format by checking
either the "CSL" or "BI Ea Per" (Bodily Injury Each Person)
box respectively. For CSL complete the first Limit field. For Split Limits complete
the BI Each Person, BI each Accident and Property Damage Limits. Medical Payments Enter the appropriate
Medical Payment limit. Uninsured Motorists Enter the appropriate
limit(s) following the liability limit format. Non-Truckers Hired/Borrowed Liability Enter state(s),
if any, in which autos are Hired or Borrowed Cost of Hire Enter the total
estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is
minimal, check the "If Any" box. The actual exposure will be determined
at time of audit. Hired/Borrowed Liability Enter state(s),
is any, in which trucks are Hired or Borrowed. Cost of Hire Enter the total
estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is
minimal, check the "If Any" box. The actual exposure will be determined
at time of audit. Non-Owned Auto Liability Enter state(s)
where employees use their own autos in the operations of the applicant's business. Group Type For Non-Owned
liability, "X" all applicable group types of. Employees, Partners
or Volunteer. For each group type indicated list the number of individuals involved. Other For additional
coverages, list the coverage name, covered auto symbol and applicable limits. Physical Damage
This section collects the coverage auto symbols for physical damage coverages. Comp/OTC If a common deductible
applies to all vehicles, enter the deductible here, or enter the individual
vehicle deductibles along with the vehicle information. Specified Causes of Loss The Specified Cause of Loss Codes are:
Collision Enter the deductible
only if it is applicable to all vehicles. Towing & Labor This coverage
is applicable only to private passenger autos. Trailer
Interchange COMP/OTC Indicate the following:
Specified Causes of Loss Indicate the following:
Collision Indicate the following:
Hired Physical Damage Indicate the
states for which coverage is to apply. Enter the estimated number of days and
number of vehicles involved. Check the applicable deductible(s) and enter the
appropriate deductible amount of liability. Indicate if this coverage is on
a primary or secondary basis by checking the appropriate box. Coverage is: Indicate if this
coverage is on a primary or secondary basis by checking the appropriate box. Other Write in additional
coverages desired, their coverage auto symbols, limits and deductibles that
may be desired. MOTOR CARRIER SECTION Coverages Place an "X"
in the appropriate Covered auto symbols box(es) for each coverage desired. Additional
information on the coverages may be found below. Covered Auto Symbols Truckers and Motor
Carrier policies use numeric symbols on the policy declarations to indicate
the type(s) of vehicles for which coverage is in effect. Be sure to place an
X in the appropriate box for each type of coverage. Only those symbols specified
for a coverage may be used. Limits For each coverage
enter the limits as they are to appear on the declarations page. Liability Indicate if the
Limit is based on a Combined Single Limit format or Split Limit format by checking
either the "CSL" or "BI Ea Per" (Bodily Injury Each Person)
box respectively. For CSL complete the first Limit field. For Split Limits complete
the BI Each Person, BI each Accident and Property Damage Limits. Medical Payments Enter the appropriate
Medical Payment limit. Uninsured Motorists Enter the appropriate
limit(s) following the liability limit format. Non-Truckers Hired/Borrowed Liability Enter state(s),
if any, in which autos are Hired or Borrowed Cost of Hire Enter the total
estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is
minimal, check the "If Any" box. The actual exposure will be determined
at time of audit. Hired/Borrowed Liability Enter state(s),
is any, in which trucks are Hired or Borrowed. Cost of Hire Enter the total
estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is
minimal, check the "If Any" box. The actual exposure will be determined
at time of audit. Non-Owned Auto Liability Enter state(s)
where employees use their own autos in the operations of the applicant's business. Group Type For Non-Owned
liability, "X" all applicable group types of. Employees, Partners
or Volunteer. For each group type indicated list the number of individuals involved. Other For additional
coverages, list the coverage name, covered auto symbol and applicable limits. Physical Damage This section collects
the coverage auto symbols for physical damage coverages. Coverages Place an "X"
in the appropriate Covered auto symbols box(es) for each coverage desired. Additional
information on the coverages may be found below. Covered Auto Symbols Truckers and Motor
Carrier policies use numeric symbols on the policy declarations to indicate
the type(s) of vehicles for which coverage is in effect. Be sure to place an
X in the appropriate box for each type of coverage. Only those symbols specified
for a coverage may be used. Limits For each coverage
enter the limits as they are to appear on the declarations page. COMP/OTC If a common deductible
applies to all vehicles, enter the deductible here, or enter the individual
vehicle deductibles along with the vehicle information. Specified Causes of Loss The Specified Cause of Loss Codes are:
Enter the deductible
only if it is applicable to all vehicles. Collision Enter the deductible only if it is applicable to all vehicles.
This coverage
is applicable only to private passenger autos. Trailer
Interchange COMP/OTC Indicate the following:
Specified Causes of Loss Indicate the following:
Collision Indicate the following:
Hired Physical Damage Indicate the
states for which coverage is to apply. Enter the estimated number of days and
number of vehicles involved. Check the applicable deductible(s) and enter the
appropriate deductible amount of liability. Indicate if this coverage is on
a primary or secondary basis by checking the appropriate box. Coverage is: Indicate if this
coverage is on a primary or secondary basis by checking the appropriate box. Other Write in additional
coverages desired, their coverage auto symbols, limits and deductibles that
may be desired. ENDORSEMENTS Enter any endorsements that apply. Be sure to include the form numbers and the required information for attaching the endorsement.
The applicant
must initial his selection of UMBI coverage. If the applicant rejects UMBI coverage,
his signature is required. Applicant's Signature The applicant
should read and understand the Fair Credit Reporting Act, the Privacy Act (where
applicable), the Applicant's Statement, and any other disclosure information
on the form before personally signing the application. Date Date the form
was signed. Producer's Signature The producer
should sign the application. This is required in most states. National Producer Number The National Producer Number assigned by the NAIC should be shown.
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