ACORD 137MD Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 137 MD (2009/12) Maryland Commercial Auto, Coverages / Limits Section The title of the form. ACORD 137 MD, Maryland Commercial Auto Coverages and 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. The following are the specific differences in this state: *Personal Injury Protection coverages are revised to reflect Maryland’s unique coverages and options. Refer to your state manual. * Underinsured Motorists coverage is included in Uninsured Motorists coverage. * Fraud Warning state-specific to Maryland * Statement added to the back of the form, referencing the state supplement, ACORD 67 MD, which must be given to the applicant if Personal Injury Protection coverage is waived.
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 Named 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.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
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.
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 the bodily injuryeach 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 Waiver of P.I.P. Check the box (if applicable): Indicates the personal injury protection (PIP) coverage has been rejected/waived.
BUSINESS AUTO Additional P.I.P – 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 Limit Enter limit: The additional personal injury protection (APIP) limit amount.
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.
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 Property Damage Enter limit: The uninsured motorists property damage per accident amount. 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.
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.
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.
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.
ENDORSEMENTS / REMARKS Endorsements / Remarks (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 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 Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Enter date: The date the form was signed by the named insured.
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 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).
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 Waiver of P.I.P. Check the box (if applicable): Indicates the personal injury protection (PIP) coverage has been rejected/waived.
TRUCKERS Additional P.I.P – 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 Limit Enter limit: The additional personal injury protection (APIP) limit amount.
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.
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 Property Damage Enter limit: The uninsured motorists property damage per accident amount. 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 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.
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 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.
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.
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 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 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.
TRUCKERS Additional Coverage Limit Enter limit: The limit amount of the other coverage.
ENDORSEMENTS / REMARKS Endorsements / Remarks (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 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 Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Enter date: The date the form was signed by the named insured.
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 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 Liability – 61 Check the box (if applicable): Indicates that any auto is covered.
MOTOR CARRIER 62 Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER 63 Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER 64 Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER 68 Check the box (if applicable): Indicates that hire autos only are covered.
MOTOR CARRIER 71 Check the box (if applicable): Indicates that non-owned autos only are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER CSL Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.
MOTOR CARRIER 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 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 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 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 Personal Injury Protection – 65 Check the box (if applicable): Indicates that owned autos subject to no-fault are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER Waiver of P.I.P. Check the box (if applicable): Indicates the personal injury protection (PIP) coverage has been rejected/waived.
MOTOR CARRIER Additional P.I.P – 65 Check the box (if applicable): Indicates that owned autos subject to no-fault are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER Limit Enter limit: The additional personal injury protection (APIP) limit amount.
MOTOR CARRIER Medical Payments – 62 Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER 63 Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER 64 Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER Each Person Enter limit: The medical payments per person limit.
MOTOR CARRIER Uninsured Motorists – 62 Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER 63 Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER 64 Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER 66 Check the box (if applicable): Indicates that owned autos subject to a compulsory uninsured motorist law are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER CSL Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.
MOTOR CARRIER 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 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 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 Property Damage Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
MOTOR CARRIER Non-Truckers Hired / Borrowed Liability – Yes Check the box (if applicable): Indicates if hired / borrowed coverage applies.
MOTOR CARRIER States Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER No Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
MOTOR CARRIER Cost of Hire Enter amount: The estimated amount it will cost to hire the vehicles.
MOTOR CARRIER 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 Hired / Borrowed Liability – Yes Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies.
MOTOR CARRIER States Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER No Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not apply.
MOTOR CARRIER Cost of Hire Enter amount: The estimated amount it will cost to hire the vehicles.
MOTOR CARRIER If Any Basis Check the box (if applicable): Indicates if the rating basis is “if any”.
MOTOR CARRIER Non-Owned Auto Liability – Yes Check the box (if applicable): Indicates if non-owned coverage applies.
MOTOR CARRIER States Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER No Check the box (if applicable): Indicates that non-owned coverage does not apply.
MOTOR CARRIER Group Type – Employees Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees.
MOTOR CARRIER Number of Employees Enter number: The number of employees that use their own automobiles.
MOTOR CARRIER Volunteers Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers.
MOTOR CARRIER Number of Volunteers Enter number: The number of volunteers that use their own automobiles.
MOTOR CARRIER Partners Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners.
MOTOR CARRIER Number of Partners Enter number: The number of partners that use their own automobiles.
MOTOR CARRIER 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 Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
MOTOR CARRIER Additional Coverage Limit Enter limit: The limit amount of the other coverage.
MOTOR CARRIER COMP / OTC – 62 Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER 63 Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER 64 Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER 68 Check the box (if applicable): Indicates that hire autos only are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER Deductible Enter deductible: The comprehensive or other than collision deductible amount.
MOTOR CARRIER Specified Causes of Loss – 62 Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER 63 Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER 64 Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER 68 Check the box (if applicable): Indicates that hire autos only are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER SCL Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
MOTOR CARRIER F Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
MOTOR CARRIER FT Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
MOTOR CARRIER FTW Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on this vehicle.
MOTOR CARRIER LSP Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on this vehicle.
MOTOR CARRIER Deductible Enter deductible: The deductible associated with specified causes of loss coverage.
MOTOR CARRIER Collision – 62 Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER 63 Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER 64 Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER 68 Check the box (if applicable): Indicates that hire autos only are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER Deductible Enter deductible: The collision deductible amount.
MOTOR CARRIER Towing & Labor – 63 Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER 67 Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER Other Covered Auto Symbol Description Enter code: The symbol code for the coverage.
MOTOR CARRIER Limit Enter limit: The towing and labor limit amount.
MOTOR CARRIER COMP / OTC – 69 Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered.
MOTOR CARRIER 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 # Trailers Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement.
MOTOR CARRIER Farth Zone Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER # 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 Radius Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors.
MOTOR CARRIER 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 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 # Trailers Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement.
MOTOR CARRIER Farth Zone Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER # 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 Radius Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors.
MOTOR CARRIER Collision – 69 Check the box (if applicable): Indicates that trailers in your possession under a trailer interchange agreement are covered.
MOTOR CARRIER 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 # Trailers Enter number: The number of trailers operated by the insured under a Trailer Interchange Agreement.
MOTOR CARRIER Farth Zone Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER # 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 Radius Enter number: The radius in actual mileage within which trailers, covered by this policy, are pulled by other tractors.
MOTOR CARRIER Deductible Enter deductible: The deductible amount applicable to trailer interchange collision coverage.
MOTOR CARRIER Hired Physical Damage – States Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER # Days Enter number: The number of days needed to rate Hired Physical Damage Coverage.
MOTOR CARRIER # Veh Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
MOTOR CARRIER Coverage is: – Primary Check the box (if applicable): Indicates if this coverage is on a primary basis.
MOTOR CARRIER Secondary Check the box (if applicable): Indicates if this coverage is on a secondary basis.
MOTOR CARRIER 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 Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
MOTOR CARRIER 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). 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).