| Section Name | Field Name | Field and/or Section Description |
| TITLE ACORD 137 FL (2009/08) | Florida Commercial Auto, Coverages / Limits Section | The title of the form. ACORD 137 FL, Florida Commercial Auto Coverages/Limits Section, is used to collect the coverage and limit information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. Refer to the forms instructions for ACORD 127 and ACORD 132 for information on those forms. The following are the specific differences in this state: * Underinsured Motorists /Bodily Injury coverage is included in Uninsured Motorists/Bodily Injury coverage; Uninsured and Underinsured Motorists Property Damage coverages are not available. * Statement added to the back of the form referencing the various Uninsured Motorists coverage options. |
| IDENTIFICATION SECTION | Agency Customer ID | Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| IDENTIFICATION SECTION | Date | Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
| IDENTIFICATION SECTION | Agency | Enter text: The full name of the producer/agency. |
| IDENTIFICATION SECTION | Policy Number | Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license orcontract number. |
| IDENTIFICATION SECTION | Effective Date | Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
| IDENTIFICATION SECTION | Carrier | Enter text: The insurer’s full legal company name(s) as found in thefile copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name. |
| IDENTIFICATION SECTION | NAIC Code | Enter code: The identification code assigned to the insurer by the NAIC. |
| IDENTIFICATION SECTION | Named Insured(s) | Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
| BUSINESS AUTO | Liability – 1 | Check the box (if applicable): Indicates that any auto is covered. |
| BUSINESS AUTO | 2 | Check the box (if applicable): Indicates that all owned autos are covered. |
| Section Name | Field Name | Field and/or Section Description |
| BUSINESS AUTO | 3 | Check the box (if applicable): Indicates that owned private passenger autos are covered. |
| BUSINESS AUTO | 4 | Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | 8 | Check the box (if applicable): Indicates that hired autos are covered. |
| BUSINESS AUTO | 9 | Check the box (if applicable): Indicates that non-owned autos are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | CSL | Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
| BUSINESS AUTO | BI Ea Per | Check the box (if applicable): Indicates if the limit shown is thebodily injury each person limit on the coverage. |
| BUSINESS AUTO | Limit | Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| BUSINESS AUTO | BI Each Accident | Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| BUSINESS AUTO | Property Damage | Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| BUSINESS AUTO | Personal Injury Protection – 5 | Check the box (if applicable): Indicates that all owned autos which require no-fault coverage are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | Named Ins Only | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured only. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| BUSINESS AUTO | Named Ins & Dep Res Rel | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured and resident relatives. |
| BUSINESS AUTO | No Deductible | Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible. |
| BUSINESS AUTO | $250 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $250. |
| BUSINESS AUTO | $500 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $500. |
| BUSINESS AUTO | $1,000 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $1000. |
| BUSINESS AUTO | Named Ins Only | Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured only. |
| BUSINESS AUTO | Named Ins & Dep Res Rel | Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured and dependent resident relatives. |
| BUSINESS AUTO | Extended PIP – 5 | Check the box (if applicable): Indicates that all owned autos which require no-fault coverage are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | Include Wk Loss | Check the box (if applicable): Indicates the extended personal injury protection (EPIP) includes work loss. |
| BUSINESS AUTO | Exclude Wk Loss | Check the box (if applicable): Indicates the extended personal injury protection (EPIP) excludes work loss. |
| BUSINESS AUTO | Additional Personal Inj Protection -5 | Check the box (if applicable): Indicates that all owned autos which require no-fault coverage are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| Section Name | Field Name | Field and/or Section Description |
| BUSINESS AUTO | Option # | Enter number: The additional personal injury protection (APIP) option number used by the company as it relates to the limit. This may be provided in lieu of the limit, or it may be sent in addition to the limit. |
| BUSINESS AUTO | Limit | Enter limit: The additional personal injury protection (APIP) limit amount. |
| BUSINESS AUTO | Include Wk Loss | Check the box (if applicable): Indicates the additional personal injury protection (APIP) includes work loss. |
| BUSINESS AUTO | Exclude Wk Loss | Check the box (if applicable): Indicates the additional personal injury protection (APIP) excludes work loss. |
| BUSINESS AUTO | Medical Payments – 2 | Check the box (if applicable): Indicates that all owned autos are covered. |
| BUSINESS AUTO | 3 | Check the box (if applicable): Indicates that owned private passenger autos are covered. |
| BUSINESS AUTO | 4 | Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | 8 | Check the box (if applicable): Indicates that hired autos are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | Each Person | Enter limit: The medical payments per person limit. |
| BUSINESS AUTO | Uninsured Motorists – 2 | Check the box (if applicable): Indicates that all owned autos are covered. |
| BUSINESS AUTO | 3 | Check the box (if applicable): Indicates that owned private passenger autos are covered. |
| BUSINESS AUTO | 4 | Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered. |
| BUSINESS AUTO | 6 | Check the box (if applicable): Indicates that owned autos subject to compulsory uninsured motorists law are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | CSL | Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
| Section Name | Field Name | Field and/or Section Description |
| BUSINESS AUTO | BI Ea Per | Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage. |
| BUSINESS AUTO | Limit | Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) |
| BUSINESS AUTO | BI Each Accident | Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. |
| BUSINESS AUTO | Hired/Borrowed Liability – Yes | Check the box (if applicable): Indicates if hired / borrowed coverage applies. |
| BUSINESS AUTO | States | Enter code: Indicates a state where autos are hired or borrowed. |
| BUSINESS AUTO | Enter code: Indicates a state where autos are hired or borrowed. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are hired or borrowed. | |
| BUSINESS AUTO | No | Check the box (if applicable): Indicates that hired / borrowed coverage does not apply. |
| BUSINESS AUTO | Cost of Hire | Enter amount: The estimated amount it will cost to hire the vehicles. |
| BUSINESS AUTO | If Any Basis | Check the box (if applicable): Indicates if the rating basis is “if any”. Check this box if the exposure is minimal. The actual exposure is determined at the time of audit. |
| BUSINESS AUTO | Non-Owned Liability – Yes | Check the box (if applicable): Indicates if non-owned coverage applies. As used here, enter state(s) where employees use their own autos in the operations of the applicant’s business. |
| BUSINESS AUTO | States | Enter code: Indicates a state where autos are non-owned. |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are non-owned. | |
| BUSINESS AUTO | No | Check the box (if applicable): Indicates that non-owned coverage does not apply. |
| BUSINESS AUTO | Group Type – Employees | Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees. |
| BUSINESS AUTO | Number of Employees | Enter number: The number of employees that use their own automobiles. |
| BUSINESS AUTO | Volunteers | Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers. |
| BUSINESS AUTO | Number of Volunteers | Enter number: The number of volunteers that use their own automobiles. |
| Section Name | Field Name | Field and/or Section Description |
| BUSINESS AUTO | Partners | Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners. |
| BUSINESS AUTO | Number of Partners | Enter number: The number of partners that use their own automobiles. |
| BUSINESS AUTO | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| BUSINESS AUTO | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| BUSINESS AUTO | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| BUSINESS AUTO | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| BUSINESS AUTO | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| BUSINESS AUTO | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| BUSINESS AUTO | Towing & Labor – 3 | Check the box (if applicable): Indicates that owned private passenger autos are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | Limit | Enter limit: The towing and labor limit amount. |
| BUSINESS AUTO | COMP / OTC – 2 | Check the box (if applicable): Indicates that all owned autos are covered. |
| BUSINESS AUTO | 3 | Check the box (if applicable): Indicates that owned private passenger autos are covered. |
| BUSINESS AUTO | 4 | Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | 8 | Check the box (if applicable): Indicates that hired autos are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| Section Name | Field Name | Field and/or Section Description |
| BUSINESS AUTO | Specified Causes of Loss – 2 | Check the box (if applicable): Indicates that all owned autos are covered. |
| BUSINESS AUTO | 3 | Check the box (if applicable): Indicates that owned private passenger autos are covered. |
| BUSINESS AUTO | 4 | Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | 8 | Check the box (if applicable): Indicates that hired autos are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | Collision – 2 | Check the box (if applicable): Indicates that all owned autos are covered. |
| BUSINESS AUTO | 3 | Check the box (if applicable): Indicates that owned private passenger autos are covered. |
| BUSINESS AUTO | 4 | Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered. |
| BUSINESS AUTO | 7 | Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered. |
| BUSINESS AUTO | 8 | Check the box (if applicable): Indicates that hired autos are covered. |
| BUSINESS AUTO | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| BUSINESS AUTO | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable. |
| BUSINESS AUTO | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| BUSINESS AUTO | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| BUSINESS AUTO | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| BUSINESS AUTO | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| BUSINESS AUTO | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| BUSINESS AUTO | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| Section Name | Field Name | Field and/or Section Description |
| BUSINESS AUTO | Hired Physical Damage – States | Enter code: Indicates a state where autos are hired and have physical damage coverage. |
| BUSINESS AUTO | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| BUSINESS AUTO | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| BUSINESS AUTO | # Days | Enter number: The number of days needed to rate Hired Physical Damage Coverage. |
| BUSINESS AUTO | # Veh | Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage. |
| BUSINESS AUTO | Coverage/Deductible – Comp | Check the box (if applicable): Indicates the deductible is for comprehensive or other than collision coverage. |
| BUSINESS AUTO | Deductible | Enter deductible: The comprehensive or other than collision deductible amount. |
| BUSINESS AUTO | Spec C of L | Check the box (if applicable): Indicates the deductible is for specified causes of loss. The Specified Cause of Loss Codes are: SCL Specified Cause of Loss F Fire F&T Fire and Theft F,T&W Fire, Theft and Wind LSP Limited Specified Perils SP Specified Perils |
| BUSINESS AUTO | Deductible | Enter deductible: The deductible associated with specified causes of loss coverage. As used here, enter the deductible only if it is applicable to all vehicles. |
| BUSINESS AUTO | Coll | Check the box (if applicable): Indicates the vehicle has collision coverage. |
| BUSINESS AUTO | Deductible | Enter deductible: The collision deductible amount. |
| BUSINESS AUTO | Coverage is: – Primary | Check the box (if applicable): Indicates if this coverage is on a primary basis. |
| BUSINESS AUTO | Secondary | Check the box (if applicable): Indicates if this coverage is on a secondary basis. |
| Section Name | Field Name | Field and/or Section Description |
| ENDORSEMENTS / REMARKS | Endorsements / Remarks | Enter text: The remarks associated with the commercial vehicle line of business. Enter any endorsements that apply. Be sure to include the form numbers and the required information for attaching the endorsement. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| SIGNATURE | Producer’s Signature | Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
| SIGNATURE | Producer’s Name (Please print) | Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. |
| SIGNATURE | State Producer License No | Enter identifier: The State License Number of the producer. |
| SIGNATURE | Applicant’s Signature | Sign here: Accommodates the signature of the applicant or named insured. |
| SIGNATURE | Date | Enter date: The date the form was signed by the named insured. |
| SIGNATURE | National Producer Number | Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. |
| IDENTIFICATION SECTION | Agency Customer ID | Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| TRUCKERS | Liability – 41 | Check the box (if applicable): Indicates that any auto is covered. |
| TRUCKERS | 42 | Check the box (if applicable): Indicates that owned autos only are covered. |
| TRUCKERS | 43 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | 47 | Check the box (if applicable): Indicates that hired autos only are covered. |
| TRUCKERS | 50 | Check the box (if applicable): Indicates that non-owned autos only are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | CSL | Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
| TRUCKERS | BI Ea Per | Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage. |
| TRUCKERS | Limit | Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | BI Each Accident | Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| TRUCKERS | Property Damage | Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| TRUCKERS | Personal Injury Protection – 44 | Check the box (if applicable): Indicates that owned autos subject to no-fault are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | Named Ins Only | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured only. |
| TRUCKERS | Named Ins & Dep Res Rel | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured and resident relatives. |
| TRUCKERS | No Deductible | Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible. |
| TRUCKERS | $250 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $250. |
| TRUCKERS | $500 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $500. |
| TRUCKERS | $1,000 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $1000. |
| TRUCKERS | Named Ins Only | Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured only. |
| TRUCKERS | Named Ins & Dep Res Rel | Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured and dependent resident relatives. |
| TRUCKERS | Extended PIP – 44 | Check the box (if applicable): Indicates that owned autos subject to no-fault are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | Include Wk Loss | Check the box (if applicable): Indicates the extended personal injury protection (EPIP) includes work loss. |
| TRUCKERS | Exclude Wk Loss | Check the box (if applicable): Indicates the extended personal injury protection (EPIP) excludes work loss. |
| TRUCKERS | Additional Personal Inj Protection -44 | Check the box (if applicable): Indicates that owned autos subject to no-fault are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | Option # | Enter number: The additional personal injury protection (APIP) option number used by the company as it relates to the limit. This may be provided in lieu of the limit, or it may be sent in addition to the limit. |
| TRUCKERS | Limit | Enter limit: The additional personal injury protection (APIP) limit amount. |
| TRUCKERS | Include Wk Loss | Check the box (if applicable): Indicates the additional personal injury protection (APIP) includes work loss. |
| TRUCKERS | Exclude Wk Loss | Check the box (if applicable): Indicates the additional personal injury protection (APIP) excludes work loss. |
| TRUCKERS | Medical Payments – 42 | Check the box (if applicable): Indicates that owned autos only are covered. |
| TRUCKERS | 43 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | Each Person | Enter limit: The medical payments per person limit. |
| TRUCKERS | Uninsured Motorists – 42 | Check the box (if applicable): Indicates that owned autos only are covered. |
| TRUCKERS | 43 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | 45 | Check the box (if applicable): Indicates that owned autos subject to a compulsory uninsured motorist law are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | CSL | Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
| TRUCKERS | BI Ea Per | Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage. |
| TRUCKERS | Limit | Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) |
| TRUCKERS | BI Each Accident | Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. |
| TRUCKERS | Non-Truckers Hired/Borrowed Liability – Yes | Check the box (if applicable): Indicates if hired / borrowed coverage applies. |
| TRUCKERS | States | Enter code: Indicates a state where autos are hired or borrowed. |
| TRUCKERS | Enter code: Indicates a state where autos are hired or borrowed. | |
| TRUCKERS | Enter code: Indicates a state where autos are hired or borrowed. | |
| TRUCKERS | No | Check the box (if applicable): Indicates that hired / borrowed coverage does not apply. |
| TRUCKERS | Cost of Hire | Enter amount: The estimated amount it will cost to hire the vehicles. |
| TRUCKERS | If Any Basis | Check the box (if applicable): Indicates if the rating basis is “if any”. Check this box if the exposure is minimal. The actual exposure is determined at the time of audit. |
| TRUCKERS | Truckers Hired/Borrowed Liability -Yes | Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies. |
| TRUCKERS | States | Enter code: Indicates a state where autos are hired or borrowed. |
| TRUCKERS | Enter code: Indicates a state where autos are hired or borrowed. | |
| TRUCKERS | Enter code: Indicates a state where autos are hired or borrowed. | |
| TRUCKERS | No | Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not apply. |
| TRUCKERS | Cost of Hire | Enter amount: The estimated amount it will cost to hire the vehicles. |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | If Any Basis | Check the box (if applicable): Indicates if the rating basis is “if any”. |
| TRUCKERS | Non-Owned Auto Liability – Yes | Check the box (if applicable): Indicates if non-owned coverage applies. |
| TRUCKERS | States | Enter code: Indicates a state where autos are non-owned. |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | Enter code: Indicates a state where autos are non-owned. | |
| TRUCKERS | No | Check the box (if applicable): Indicates that non-owned coverage does not apply. |
| TRUCKERS | Group Type – Employees | Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees. |
| TRUCKERS | Number of Employees | Enter number: The number of employees that use their own automobiles. |
| TRUCKERS | Volunteers | Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers. |
| TRUCKERS | Number of Volunteers | Enter number: The number of volunteers that use their own automobiles. |
| TRUCKERS | Partners | Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners. |
| TRUCKERS | Number of Partners | Enter number: The number of partners that use their own automobiles. |
| TRUCKERS | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| TRUCKERS | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| TRUCKERS | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| TRUCKERS | COMP / OTC – 42 | Check the box (if applicable): Indicates that owned autos only are covered. |
| TRUCKERS | 43 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | 47 | Check the box (if applicable): Indicates that hired autos only are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | Deductible | Enter deductible: The comprehensive or other than collision deductible amount. |
| TRUCKERS | Specified Causes of Loss – 42 | Check the box (if applicable): Indicates that owned autos only are covered. |
| TRUCKERS | 43 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | 47 | Check the box (if applicable): Indicates that hired autos only are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | SCL | Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage. |
| TRUCKERS | F | Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle. |
| TRUCKERS | FT | Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle. |
| TRUCKERS | FTW | Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on this vehicle. |
| TRUCKERS | LSP | Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on this vehicle. |
| TRUCKERS | Deductible | Enter deductible: The deductible associated with specified causes of loss coverage. |
| TRUCKERS | Collision – 42 | Check the box (if applicable): Indicates that owned autos only are covered. |
| TRUCKERS | 43 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| TRUCKERS | 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | 47 | Check the box (if applicable): Indicates that hired autos only are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | Deductible | Enter deductible: The collision deductible amount. |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | Towing & Labor – 46 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| TRUCKERS | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| TRUCKERS | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| TRUCKERS | Limit | Enter limit: The towing and labor limit amount. |
| TRUCKERS | COMP / OTC – 48 | Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered. |
| TRUCKERS | 49 | Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered. |
| TRUCKERS | # Trailers | Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement. |
| TRUCKERS | Farth Zone | Enter code: The state of the farthest zone where trailer interchange coverage applies. |
| TRUCKERS | # Days | Enter number: The number of days during one year in which this exposure exists; that is, the number of days in which the insured pulls trailers that are in his possession under a Trailer Interchange Agreement. |
| TRUCKERS | Radius | Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors. |
| TRUCKERS | Specified Causes of Loss – 48 | Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered. |
| TRUCKERS | 49 | Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered. |
| TRUCKERS | # Trailers | Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement. |
| TRUCKERS | Farth Zone | Enter code: The state of the farthest zone where trailer interchange coverage applies. |
| TRUCKERS | # Days | Enter number: The number of days during one year in which this exposure exists; that is, the number of days in which the insured pulls trailers that are in his possession under a Trailer Interchange Agreement. |
| TRUCKERS | Radius | Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors. |
| TRUCKERS | Collision – 48 | Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered. |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | 49 | Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered. |
| TRUCKERS | # Trailers | Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement. |
| TRUCKERS | Farth Zone | Enter code: The state of the farthest zone where trailer interchange coverage applies. |
| TRUCKERS | # Days | Enter number: The number of days during one year in which this exposure exists; that is, the number of days in which the insured pulls trailers that are in his possession under a Trailer Interchange Agreement. |
| TRUCKERS | Radius | Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors. |
| TRUCKERS | Deductible | Enter deductible: The deductible amount applicable to trailer interchange collision coverage. |
| TRUCKERS | Hired Physical Damage – States | Enter code: Indicates a state where autos are hired and have physical damage coverage. |
| TRUCKERS | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| TRUCKERS | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| TRUCKERS | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| TRUCKERS | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| TRUCKERS | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| TRUCKERS | # Days | Enter number: The number of days needed to rate Hired Physical Damage Coverage. |
| TRUCKERS | # Veh | Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage. |
| TRUCKERS | Coverage is: – Primary | Check the box (if applicable): Indicates if this coverage is on a primary basis. |
| TRUCKERS | Secondary | Check the box (if applicable): Indicates if this coverage is on a secondary basis. |
| TRUCKERS | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| TRUCKERS | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| Section Name | Field Name | Field and/or Section Description |
| TRUCKERS | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| ENDORSEMENTS / REMARKS | Endorsements / Remarks | Enter text: The remarks associated with the commercial vehicle line of business. Enter any endorsements that apply. Be sure to include the form numbers and the required information for attaching the endorsement. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| SIGNATURE | Producer’s Signature | Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
| SIGNATURE | Producer’s Name (Please print) | Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. |
| SIGNATURE | State Producer License No | Enter identifier: The State License Number of the producer. |
| SIGNATURE | Applicant’s Signature | Sign here: Accommodates the signature of the applicant or named insured. |
| SIGNATURE | Date | Enter date: The date the form was signed by the named insured. |
| SIGNATURE | National Producer Number | Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. |
| IDENTIFICATION SECTION | Agency Customer ID | Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| MOTOR CARRIER SECTION | Liability – 61 | Check the box (if applicable): Indicates that any auto is covered. |
| MOTOR CARRIER SECTION | 62 | Check the box (if applicable): Indicates that owned autos only are covered. |
| MOTOR CARRIER SECTION | 63 | Check the box (if applicable): Indicates that owned private passenger autos only are covered. |
| MOTOR CARRIER SECTION | 64 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | 68 | Check the box (if applicable): Indicates that hire autos only are covered. |
| MOTOR CARRIER SECTION | 71 | Check the box (if applicable): Indicates that non-owned autos only are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| Section Name | Field Name | Field and/or Section Description |
| MOTOR CARRIER SECTION | CSL | Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
| MOTOR CARRIER SECTION | BI Ea Per | Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage. |
| MOTOR CARRIER SECTION | Limit | Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| MOTOR CARRIER SECTION | BI Each Accident | Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| MOTOR CARRIER SECTION | Property Damage | Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| MOTOR CARRIER SECTION | Personal Injury Protection – 65 | Check the box (if applicable): Indicates that owned autos subject to no-fault are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | Named Ins Only | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured only. |
| MOTOR CARRIER SECTION | Named Ins & Dep Res Rel | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to the named insured and resident relatives. |
| MOTOR CARRIER SECTION | No Deductible | Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible. |
| MOTOR CARRIER SECTION | $250 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $250. |
| MOTOR CARRIER SECTION | $500 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $500. |
| MOTOR CARRIER SECTION | $1,000 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $1000. |
| MOTOR CARRIER SECTION | Named Ins Only | Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured only. |
| Section Name | Field Name | Field and/or Section Description |
| MOTOR CARRIER SECTION | Named Ins & Dep Res Rel | Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion applies to the named insured and dependent resident relatives. |
| MOTOR CARRIER SECTION | Extended PIP – 65 | Check the box (if applicable): Indicates that owned autos subject to no-fault are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | Include Wk Loss | Check the box (if applicable): Indicates the extended personal injury protection (EPIP) includes work loss. |
| MOTOR CARRIER SECTION | Exclude Wk Loss | Check the box (if applicable): Indicates the extended personal injury protection (EPIP) excludes work loss. |
| MOTOR CARRIER SECTION | Additional Personal Inj Protection -65 | Check the box (if applicable): Indicates that owned autos subject to no-fault are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | Option # | Enter number: The additional personal injury protection (APIP) option number used by the company as it relates to the limit. This may be provided in lieu of the limit, or it may be sent in addition to the limit. |
| MOTOR CARRIER SECTION | Limit | Enter limit: The additional personal injury protection (APIP) limit amount. |
| MOTOR CARRIER SECTION | Include Wk Loss | Check the box (if applicable): Indicates the additional personal injury protection (APIP) includes work loss. |
| MOTOR CARRIER SECTION | Exclude Wk Loss | Check the box (if applicable): Indicates the additional personal injury protection (APIP) excludes work loss. |
| MOTOR CARRIER SECTION | Medical Payments – 62 | Check the box (if applicable): Indicates that owned autos only are covered. |
| MOTOR CARRIER SECTION | 63 | Check the box (if applicable): Indicates that owned private passenger autos only are covered. |
| Section Name | Field Name | Field and/or Section Description |
| MOTOR CARRIER SECTION | 64 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | Each Person | Enter limit: The medical payments per person limit. |
| MOTOR CARRIER SECTION | Uninsured Motorists – 62 | Check the box (if applicable): Indicates that owned autos only are covered. |
| MOTOR CARRIER SECTION | 63 | Check the box (if applicable): Indicates that owned private passenger autos only are covered. |
| MOTOR CARRIER SECTION | 64 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| MOTOR CARRIER SECTION | 66 | Check the box (if applicable): Indicates that owned autos subject to a compulsory uninsured motorist law are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | CSL | Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
| MOTOR CARRIER SECTION | BI Ea Per | Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage. |
| MOTOR CARRIER SECTION | Limit | Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.) |
| MOTOR CARRIER SECTION | BI Each Accident | Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. |
| MOTOR CARRIER SECTION | Non-Truckers Hired/Borrowed Liability – Yes | Check the box (if applicable): Indicates if hired / borrowed coverage applies. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| MOTOR CARRIER SECTION | States | Enter code: Indicates a state where autos are hired or borrowed. |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired or borrowed. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired or borrowed. | |
| MOTOR CARRIER SECTION | No | Check the box (if applicable): Indicates that hired / borrowed coverage does not apply. |
| MOTOR CARRIER SECTION | Cost of Hire | Enter amount: The estimated amount it will cost to hire the vehicles. |
| MOTOR CARRIER SECTION | If Any Basis | Check the box (if applicable): Indicates if the rating basis is “if any”. Check this box if the exposure is minimal. The actual exposure is determined at the time of audit. |
| MOTOR CARRIER SECTION | Truckers Hired/Borrowed Liability -Yes | Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies. |
| MOTOR CARRIER SECTION | States | Enter code: Indicates a state where autos are hired or borrowed. |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired or borrowed. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired or borrowed. | |
| MOTOR CARRIER SECTION | No | Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not apply. |
| MOTOR CARRIER SECTION | Cost of Hire | Enter amount: The estimated amount it will cost to hire the vehicles. |
| MOTOR CARRIER SECTION | If Any Basis | Check the box (if applicable): Indicates if the rating basis is “if any”. |
| MOTOR CARRIER SECTION | Non-Owned Auto Liability – Yes | Check the box (if applicable): Indicates if non-owned coverage applies. |
| MOTOR CARRIER SECTION | States | Enter code: Indicates a state where autos are non-owned. |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. |
| Section Name | Field Name | Field and/or Section Description |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are non-owned. | |
| MOTOR CARRIER SECTION | No | Check the box (if applicable): Indicates that non-owned coverage does not apply. |
| MOTOR CARRIER SECTION | Group Type – Employees | Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees. |
| MOTOR CARRIER SECTION | Number of Employees | Enter number: The number of employees that use their own automobiles. |
| MOTOR CARRIER SECTION | Volunteers | Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers. |
| MOTOR CARRIER SECTION | Number of Volunteers | Enter number: The number of volunteers that use their own automobiles. |
| MOTOR CARRIER SECTION | Partners | Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners. |
| MOTOR CARRIER SECTION | Number of Partners | Enter number: The number of partners that use their own automobiles. |
| MOTOR CARRIER SECTION | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| MOTOR CARRIER SECTION | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| MOTOR CARRIER SECTION | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| MOTOR CARRIER SECTION | COMP / OTC – 62 | Check the box (if applicable): Indicates that owned autos only are covered. |
| MOTOR CARRIER SECTION | 63 | Check the box (if applicable): Indicates that owned private passenger autos only are covered. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| MOTOR CARRIER SECTION | 64 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | 68 | Check the box (if applicable): Indicates that hire autos only are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | Deductible | Enter deductible: The comprehensive or other than collision deductible amount. |
| MOTOR CARRIER SECTION | Specified Causes of Loss – 62 | Check the box (if applicable): Indicates that owned autos only are covered. |
| MOTOR CARRIER SECTION | 63 | Check the box (if applicable): Indicates that owned private passenger autos only are covered. |
| MOTOR CARRIER SECTION | 64 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | 68 | Check the box (if applicable): Indicates that hire autos only are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | SCL | Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage. |
| MOTOR CARRIER SECTION | F | Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle. |
| MOTOR CARRIER SECTION | FT | Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle. |
| MOTOR CARRIER SECTION | FTW | Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on this vehicle. |
| MOTOR CARRIER SECTION | LSP | Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on this vehicle. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| MOTOR CARRIER SECTION | Deductible | Enter deductible: The deductible associated with specified causes of loss coverage. |
| MOTOR CARRIER SECTION | Collision – 62 | Check the box (if applicable): Indicates that owned autos only are covered. |
| MOTOR CARRIER SECTION | 63 | Check the box (if applicable): Indicates that owned private passenger autos only are covered. |
| MOTOR CARRIER SECTION | 64 | Check the box (if applicable): Indicates that owned commercial autos only are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | 68 | Check the box (if applicable): Indicates that hire autos only are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | Deductible | Enter deductible: The collision deductible amount. |
| MOTOR CARRIER SECTION | Towing & Labor – 63 | Check the box (if applicable): Indicates that owned private passenger autos only are covered. |
| MOTOR CARRIER SECTION | 67 | Check the box (if applicable): Indicates that specifically described autos are covered. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol | Check the box (if applicable): Indicates that a symbol other than those listed should be used. |
| MOTOR CARRIER SECTION | Other Covered Auto Symbol Description | Enter code: The symbol code for the coverage. |
| MOTOR CARRIER SECTION | Limit | Enter limit: The towing and labor limit amount. |
| MOTOR CARRIER SECTION | COMP / OTC – 69 | Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered. |
| MOTOR CARRIER SECTION | 70 | Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered. |
| MOTOR CARRIER SECTION | # Trailers | Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement. |
| MOTOR CARRIER SECTION | Farth Zone | Enter code: The state of the farthest zone where trailer interchange coverage applies. |
| Section Name | Field Name | Field and/or Section Description |
| MOTOR CARRIER SECTION | # Days | Enter number: The number of days during one year in which this exposure exists; that is, the number of days in which the insured pulls trailers that are in his possession under a Trailer Interchange Agreement. |
| MOTOR CARRIER SECTION | Radius | Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors. |
| MOTOR CARRIER SECTION | Specified Causes of Loss – 69 | Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered. |
| MOTOR CARRIER SECTION | 70 | Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered. |
| MOTOR CARRIER SECTION | # Trailers | Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement. |
| MOTOR CARRIER SECTION | Farth Zone | Enter code: The state of the farthest zone where trailer interchange coverage applies. |
| MOTOR CARRIER SECTION | # Days | Enter number: The number of days during one year in which this exposure exists; that is, the number of days in which the insured pulls trailers that are in his possession under a Trailer Interchange Agreement. |
| MOTOR CARRIER SECTION | Radius | Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors. |
| MOTOR CARRIER SECTION | Collision – 69 | Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered. |
| MOTOR CARRIER SECTION | 70 | Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered. |
| MOTOR CARRIER SECTION | # Trailers | Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement. |
| MOTOR CARRIER SECTION | Farth Zone | Enter code: The state of the farthest zone where trailer interchange coverage applies. |
| MOTOR CARRIER SECTION | # Days | Enter number: The number of days during one year in which this exposure exists; that is, the number of days in which the insured pulls trailers that are in his possession under a Trailer Interchange Agreement. |
| MOTOR CARRIER SECTION | Radius | Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors. |
| MOTOR CARRIER SECTION | Deductible | Enter deductible: The deductible amount applicable to trailer interchange collision coverage. |
| MOTOR CARRIER SECTION | Hired Physical Damage – States | Enter code: Indicates a state where autos are hired and have physical damage coverage. |
| Section Name | Field Name | Field and/or Section Description |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| MOTOR CARRIER SECTION | Enter code: Indicates a state where autos are hired and have physical damage coverage. | |
| MOTOR CARRIER SECTION | # Days | Enter number: The number of days needed to rate Hired Physical Damage Coverage. |
| MOTOR CARRIER SECTION | # Veh | Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage. |
| MOTOR CARRIER SECTION | Coverage is: – Primary | Check the box (if applicable): Indicates if this coverage is on a primary basis. |
| MOTOR CARRIER SECTION | Secondary | Check the box (if applicable): Indicates if this coverage is on a secondary basis. |
| MOTOR CARRIER SECTION | Additional Coverage Description | Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| MOTOR CARRIER SECTION | Additional Coverage Covered Auto Symbols | Enter text: The symbols that apply to the other coverage listed. |
| MOTOR CARRIER SECTION | Additional Coverage Limit | Enter limit: The limit amount of the other coverage. |
| ENDORSEMENTS / REMARKS | Endorsements / Remarks | Enter text: The remarks associated with the commercial vehicle line of business. Enter any endorsements that apply. Be sure to include the form numbers and the required information for attaching the endorsement. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| SIGNATURE | Producer’s Signature | Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
| SIGNATURE | Producer’s Name (Please print) | Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. |
| SIGNATURE | State Producer License No | Enter identifier: The State License Number of the producer. |
| SIGNATURE | Applicant’s Signature | Sign here: Accommodates the signature of the applicant or named insured. |
| Section Name | Field Name | Field and/or Section Description |
| SIGNATURE | Date | Enter date: The date the form was signed by the named insured. |
| SIGNATURE | National Producer Number | Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. |
| Edition | Date | The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |