ACORD 137GA Instructions


Universal wording updates to improve clarity and intent were made to all FIG text for this form on 12/29/2008.
Section Name Field Name Field and/or Section Description
TITLE ACORD 137 GA (2009/02) Georgia Commercial Auto, Coverages / Limits Section The title of the form. ACORD 137 GA, Georgia Commercial Auto, 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.
TITLE ACORD 137 GA (2009/02) The following are the specific differences in this state: *Personal Injury Protection coverage does not apply; this is not a “not-fault” state * Uninsured Motorists coverage includes Underinsured Motorists coverage; provision is made for per-accident deductibles under Uninsured Motorists coverage * Page 1, Business Auto; required statement has been added indicating that Traditional (Reduced) Uninsured Motorist and, if applicable, New (Added On) Uninsured Motorist coverages have been offered and explained to the applicant. New (Added On) Uninsured Motorist coverage is only available for vehicles qualifying as private passenger type vehicles under Georgia law. * Page 2 and 3, Truckers and Motor Carrier; required statement has been added to the form indicating that Uninsured Motorist coverage has been offered and explained to the applicant * Traditional and New Uninsured Motorist Coverage Mandatory Offer and Explanation is page 4 of theapplication * Example of New Uninsured Motorist Coverage and Traditional Uninsured Motorist Coverage Claim Payment Calculation is page 5 of the application”
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 or contract 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 Name Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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. As used here, this may contain the name of the residual market plan.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
BUSINESS AUTO SECTION Liability – 1 Check the box (if applicable): Indicates that any auto is covered.
BUSINESS AUTO SECTION 2 Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 4 Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION 8 Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION 9 Check the box (if applicable): Indicates that non-owned autos are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 SECTION CSL Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.
BUSINESS AUTO SECTION BI Ea Per Check the box (if applicable): Indicates if the limit shown is thebodily injury each person limit on the coverage.
BUSINESS AUTO 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).
BUSINESS AUTO 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).
BUSINESS AUTO 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).
BUSINESS AUTO SECTION Medical Payments – 2 Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 4 Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION 8 Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 SECTION Each Person Enter limit: The medical payments per person limit.
BUSINESS AUTO SECTION Traditional (Reduced) Uninsured Motorists – 2 Check the box (if applicable): Indicates that all owned autos are covered. As used here, this is the traditional (reduced) uninsured motorists.
BUSINESS AUTO SECTION 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 4 Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered.
BUSINESS AUTO SECTION 6 Check the box (if applicable): Indicates that owned autos subject to compulsory uninsured motorists law are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 SECTION CSL Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.
BUSINESS AUTO SECTION 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 SECTION Ded Enter deductible: The uninsured motorists combined single limit deductible amount.
BUSINESS AUTO 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.)
BUSINESS AUTO SECTION Ded Enter deductible: The uninsured motorists bodily injury deductible amount.
BUSINESS AUTO 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.
BUSINESS AUTO SECTION Ded Enter deductible: The uninsured motorists property damage deductible amount.
BUSINESS AUTO SECTION Property Damage Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
BUSINESS AUTO SECTION New (Added On)Uninsured Motorist – 2 Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 4 Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered.
BUSINESS AUTO SECTION 6 Check the box (if applicable): Indicates that owned autos subject to compulsory uninsured motorists law are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 SECTION CSL Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.
BUSINESS AUTO SECTION 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 SECTION Ded Enter deductible: The uninsured motorists combined single limit deductible amount.
BUSINESS AUTO 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.)
BUSINESS AUTO SECTION Ded Enter deductible: The uninsured motorists bodily injury deductible amount.
BUSINESS AUTO 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.
BUSINESS AUTO SECTION Ded Enter deductible: The uninsured motorists property damage deductible amount.
BUSINESS AUTO SECTION Property Damage Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
BUSINESS AUTO SECTION Hired / Borrowed Liability – Yes Check the box (if applicable): Indicates if hired / borrowed coverage applies.
BUSINESS AUTO SECTION States Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO SECTION No Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
BUSINESS AUTO SECTION Cost of Hire Enter amount: The estimated amount it will cost to hire the vehicles.
BUSINESS AUTO 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.
BUSINESS AUTO SECTION 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 SECTION States Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION No Check the box (if applicable): Indicates that non-owned coverage does not apply.
BUSINESS AUTO SECTION Group Type – Employees Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees.
BUSINESS AUTO SECTION Number of Employees Enter number: The number of employees that use their own automobiles.
BUSINESS AUTO SECTION Volunteers Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers.
BUSINESS AUTO SECTION Number of Volunteers Enter number: The number of volunteers that use their own automobiles.
BUSINESS AUTO SECTION Partners Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners.
BUSINESS AUTO SECTION Number of Partners Enter number: The number of partners that use their own automobiles.
BUSINESS AUTO 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).
BUSINESS AUTO SECTION Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO SECTION Additional Coverage Limit Enter limit: The limit amount of the other coverage.
BUSINESS AUTO 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).
BUSINESS AUTO SECTION Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO SECTION Additional Coverage Limit Enter limit: The limit amount of the other coverage.
BUSINESS AUTO SECTION Towing & Labor – 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 SECTION Limit Enter limit: The towing and labor limit amount.
BUSINESS AUTO SECTION COMP / OTC – 2 Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 4 Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION 8 Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 SECTION Specified Causes of Loss – 2 Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 4 Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION 8 Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 SECTION Collision – 2 Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION 3 Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION 4 Check the box (if applicable): Indicates that owned autos other than private passenger autos are covered.
BUSINESS AUTO SECTION 7 Check the box (if applicable): Indicates that autos specified on the vehicle schedule are covered.
BUSINESS AUTO SECTION 8 Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION 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 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).
BUSINESS AUTO SECTION Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO SECTION Additional Coverage Limit Enter limit: The limit amount of the other coverage.
BUSINESS AUTO 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).
BUSINESS AUTO SECTION Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO SECTION Additional Coverage Limit Enter limit: The limit amount of the other coverage.
BUSINESS AUTO SECTION Hired Physical Damage – States Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION # Days Enter number: The number of days needed to rate Hired Physical Damage Coverage.
BUSINESS AUTO SECTION # Veh Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
BUSINESS AUTO SECTION Coverage / Deductible – Comp Check the box (if applicable): Indicates the deductible is for comprehensive coverage.
BUSINESS AUTO SECTION Deductible Enter deductible: The comprehensive or other than collision deductible amount.
BUSINESS AUTO SECTION 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 SECTION 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 SECTION Coll Check the box (if applicable): Indicates the vehicle has collision coverage.
BUSINESS AUTO SECTION Deductible Enter deductible: The collision deductible amount.
BUSINESS AUTO SECTION Coverage is: – Primary Check the box (if applicable): Indicates if this coverage is on a primary basis.
BUSINESS AUTO SECTION Secondary Check the box (if applicable): Indicates if this coverage is on a secondary basis.
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 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 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 National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
TRUCKERS SECTION Liability – 41 Check the box (if applicable): Indicates that any auto is covered.
TRUCKERS SECTION 42 Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION 43 Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION 46 Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION 47 Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION 50 Check the box (if applicable): Indicates that non-owned autos only are covered.
TRUCKERS SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
TRUCKERS SECTION CSL Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.
TRUCKERS SECTION BI Ea Per Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage.
TRUCKERS 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).
TRUCKERS 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).
TRUCKERS 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).
TRUCKERS SECTION Medical Payments – 42 Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION 43 Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION 46 Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
TRUCKERS SECTION Each Person Enter limit: The medical payments per person limit.
TRUCKERS SECTION Uninsured Motorists – 42 Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION 43 Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION 45 Check the box (if applicable): Indicates that owned autos subject to a compulsory uninsured motorist law are covered.
TRUCKERS SECTION 46 Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
TRUCKERS SECTION CSL Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.
TRUCKERS SECTION BI Ea Per Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage.
TRUCKERS SECTION Ded Enter deductible: The uninsured motorists combined single limit deductible amount.
TRUCKERS 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.)
TRUCKERS SECTION Ded Enter deductible: The uninsured motorists bodily injury deductible amount.
TRUCKERS 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.
TRUCKERS SECTION Ded Enter deductible: The uninsured motorists property damage deductible amount.
TRUCKERS SECTION Property Damage Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
TRUCKERS SECTION Non-Truckers Hired / Borrowed Liability – Yes Check the box (if applicable): Indicates if hired / borrowed coverage applies.
TRUCKERS SECTION States Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION No Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
TRUCKERS SECTION Cost of Hire Enter amount: The estimated amount it will cost to hire the vehicles.
TRUCKERS 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.
TRUCKERS SECTION Truckers Hired / Borrowed Liability – Yes Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies.
TRUCKERS SECTION States Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION No Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not apply.
TRUCKERS SECTION Cost of Hire Enter amount: The estimated amount it will cost to hire the vehicles.
TRUCKERS SECTION If Any Basis Check the box (if applicable): Indicates if the rating basis is “if any”.
TRUCKERS SECTION Non-Owned Auto Liability – Yes Check the box (if applicable): Indicates if non-owned coverage applies.
TRUCKERS SECTION States Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION No Check the box (if applicable): Indicates that non-owned coverage does not apply.
TRUCKERS SECTION Group Type – Employees Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees.
TRUCKERS SECTION Number of Employees Enter number: The number of employees that use their own automobiles.
TRUCKERS SECTION Volunteers Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers.
TRUCKERS SECTION Number of Volunteers Enter number: The number of volunteers that use their own automobiles.
TRUCKERS SECTION Partners Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners.
TRUCKERS SECTION Number of Partners Enter number: The number of partners that use their own automobiles.
TRUCKERS 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).
TRUCKERS SECTION Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
TRUCKERS SECTION Additional Coverage Limit Enter limit: The limit amount of the other coverage.
TRUCKERS 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).
TRUCKERS SECTION Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
TRUCKERS SECTION Additional Coverage Limit Enter limit: The limit amount of the other coverage.
TRUCKERS SECTION COMP / OTC – 42 Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION 43 Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION 46 Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION 47 Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
TRUCKERS SECTION Deductible Enter deductible: The comprehensive or other than collision deductible amount.
TRUCKERS SECTION Specified Causes of Loss – 42 Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION 43 Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION 46 Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION 47 Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
TRUCKERS SECTION SCL Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
TRUCKERS SECTION F Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
TRUCKERS SECTION FT Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
TRUCKERS SECTION FTW Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on this vehicle.
TRUCKERS SECTION LSP Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on this vehicle.
TRUCKERS SECTION Deductible Enter deductible: The deductible associated with specified causes of loss coverage.
TRUCKERS SECTION Collision – 42 Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION 43 Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION 46 Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION 47 Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
TRUCKERS SECTION Deductible Enter deductible: The collision deductible amount.
TRUCKERS SECTION Towing & Labor – 46 Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
TRUCKERS SECTION Limit Enter limit: The towing and labor limit amount.
TRUCKERS SECTION COMP / OTC – 48 Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered.
TRUCKERS SECTION 49 Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered.
TRUCKERS SECTION # Trailers Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement.
TRUCKERS SECTION Farth Zone Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS 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.
TRUCKERS SECTION Radius Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors.
TRUCKERS SECTION Specified Causes of Loss – 48 Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered.
TRUCKERS SECTION 49 Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered.
TRUCKERS SECTION # Trailers Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement.
TRUCKERS SECTION Farth Zone Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS 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.
TRUCKERS SECTION Radius Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors.
TRUCKERS SECTION Collision – 48 Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered.
TRUCKERS SECTION 49 Check the box (if applicable): Indicates that your trailers in the possession of another trucker under a trailer interchange agreement are covered.
TRUCKERS SECTION # Trailers Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement.
TRUCKERS SECTION Farth Zone Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS 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.
TRUCKERS SECTION Radius Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors.
TRUCKERS SECTION Deductible Enter deductible: The deductible amount applicable to trailer interchange collision coverage.
TRUCKERS SECTION Hired Physical Damage – States Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION # Days Enter number: The number of days needed to rate Hired Physical Damage Coverage.
TRUCKERS SECTION # Veh Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
TRUCKERS SECTION Coverage is: – Primary Check the box (if applicable): Indicates if this coverage is on a primary basis.
TRUCKERS SECTION Secondary Check the box (if applicable): Indicates if this coverage is on a secondary basis.
TRUCKERS 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).
TRUCKERS SECTION Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
TRUCKERS 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 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 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 National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR).
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.
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 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.
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 Each Person Enter limit: The medical payments per person limit.
MOTOR CARRIER SECTION Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
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 Ded Enter deductible: The uninsured motorists combined single limit deductible amount.
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 Ded Enter deductible: The uninsured motorists bodily injury deductible 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 Ded Enter deductible: The uninsured motorists property damage deductible amount.
MOTOR CARRIER SECTION Property Damage Enter limit: The uninsured motorists property damage per accident amount. 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.
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.
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.
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.
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.
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.
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 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 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 National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
INITIALS I accept Traditional Uninsured Motorist Coverage Initial here: The named insured’s initials. As used here, indicates the named insured has selected traditional (reduced) uninsured motorists coverage.
INITIALS I accept New Uninsured Motorist Coverage Initial here: The named insured’s initials. As used here, indicates the named insured has selected new (added on) uninsured motorists coverage.
INITIALS I reject ALL Uninsured Motorist Coverage Initial here: The named insured’s initials. As used here, indicates the named insured has rejected all uninsured motorists coverage.
TRADITIONAL AND NEW UNINSURED MOTORIST COVERAGE MANDATORY OFFER AND EXPLANATION Applicant’s Signature Sign here: Accommodates the signature of the applicant or named insured.
TRADITIONAL AND NEW UNINSURED MOTORIST COVERAGE MANDATORY OFFER AND EXPLANATION Date Enter date: The date the form was signed by the named insured.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).