ACORD 137 NJ (2004/11) – New Jersey Commercial Auto, Coverages/Limits Section

Use ACORD 137 NJ to collect the coverage, limits and premium 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 have been revised to provide for unique New Jersey coverages. Refer to your state Manual.
* Uninsured and Underinsured Motorists coverages are combined.
* Comprehensive is known as “other than collision coverage”.
* The fraud statement on the back of the form is revised to comply with New Jersey law.
* A statement has been added referencing the offer of Uninsured/Underinsured Motorists coverage up to the policy’s BI limits.

IDENTIFICATION SECTION

Date

Month/day/year (MM/DD/YYYY) on which the form is completed.

Producer

Producer’s name.

Applicant (First Name Insured)

Full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith).

BUSINESS AUTO

Coverages

Place an “X” in the appropriate Covered auto symbols box(es) for each coverage desired. Additional information on the coverages may be found below.

Covered Auto Symbols

Business Auto policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used.

Limits

For each coverage enter the limits as they are to appear on the declarations page.

Liability

Indicate if the Limit is based on a Combined Single Limit format or Split Limit format by checking either the “CSL” or “BI Ea Per” (Bodily InjuryEach Person) box respectively. For CSL complete the first Limit field. For Split Limits complete the BI Each Person BI each accident and Property Damage Limits.

Personal Injury Protection

Refer to applicable State Manual For Options. Include any deductible selected by the applicant.

Extra P.I.P. Options

Refer to applicable State Manual for Options.

Medical Payments

The desired Per Person Limit.

Uninsured/Underinsured Motorists

Enter the appropriate limit(s) following the Liability Limit Format. Symbol 6 applies only in states where rejection is not permitted by law.

Hired/Borrowed Liability

Enter state(s), if any, in which autos are Hired or Borrowed

Cost of Hire

Enter the total estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is minimal, check the “If Any” box. The actual exposure will be determined at time of audit.

Non-Owned Liability

Enter state(s) where employees use their own autos in the operations of the applicant’s business.

Group Type

For Non-Owned liability, “X” all applicable group types of. Employees, Partners or Volunteer. For each group type indicated list the number of individuals involved.

Blank Area

Write in additional coverages desired, their coverage auto symbols and limits in the available boxes. Use the endorsements section if necessary.

Physical Damage

This section collects the coverage auto symbols for physical damage coverages. Information on deductible and valuation types is collected elsewhere within the individual Vehicle Description sections. Available coverage options are:

* Towing & Labor- This coverage is applicable only to private passenger autos.
* Specified Causes of Loss
* Comprehensive (other than Collision)
* Collision

Towing & Labor

This coverage is applicable only to private passenger autos.

Comprehensive / OTC

Check the applicable box(es).

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

Enter the deductible only if it is applicable to all vehicles.

Collision

Enter the deductible only if it is applicable to all vehicles.

Hired Physical Damage

Indicate the states for which coverage is to apply. Enter the estimated number of days and number of vehicles involved.

Coverage/Deductible

Check the applicable coverage(s) and enter the appropriate deductible amount of liability.

Coverage is:

Indicate if this coverage is on a primary or secondary basis by checking the appropriate box.

TRUCKERS

Coverages

Place an “X” in the appropriate Covered auto symbols box(es) for each coverage desired. Additional information on the coverages may be found below.

Covered Auto Symbols

Truckers and Motor Carrier policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used.

Limits

For each coverage enter the limits as they are to appear on the declarations page.

Liability

Indicate if the Limit is based on a Combined Single Limit format or Split Limit format by checking either the “CSL” or “BI Ea Per” (Bodily Injury Each Person) box respectively. For CSL complete the first Limit field. For Split Limits complete the BI Each Person, BI each Accident and Property Damage Limits.

Personal Injury Protection

Refer to applicable State Manual for Options. Include any deductible selected by the applicant.

Extra P.I.P. Options

Refer to applicable State Manual for Options.

Medical Payments

Enter the appropriate Medical Payment limit.

Uninsured/Underinsured Motorists

Enter the appropriate limit(s) following the liability limit format.

Non-Truckers Hired/Borrowed Liability

Enter state(s), if any, in which autos are Hired or Borrowed

Cost of Hire

Enter the total estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is minimal, check the “If Any” box. The actual exposure will be determined at time of audit.

Hired/Borrowed Liability

Enter state(s), if any, in which trucks are Hired or Borrowed.

Cost of Hire

Enter the total estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is minimal, check the “If Any” box. The actual exposure will be determined at time of audit.

Non-Owned Auto Liability

Enter state(s) where employees use their own autos in the operations of the applicant’s business.

Group Type

For Non-Owned liability, “X” all applicable group types of. Employees, Partners or Volunteer. For each group type indicated list the number of individuals involved.

Other

For additional coverages, list the coverage name, covered auto symbol and applicable limits.

Physical Damage

This section collects the coverage auto symbols for physical damage coverages.

Comprehensive / OTC

If a common deductible applies to all vehicles, enter the deductible here, or enter the individual vehicle deductibles along with the vehicle information.

Specified Causes of Loss

The Specified Cause of Loss Codes are:

• 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

Enter the deductible only if it is applicable to all vehicles.

Collision

Enter the deductible only if it is applicable to all vehicles.

Towing & Labor

This coverage is applicable only to private passenger autos.

Trailer Interchange

Comprehensive / OTC

Indicate the following:

• # Trailer – The number of trailers involved in the interchange agreement for the chosen coverage
• State – The states involved in the trailer interchange agreement
• # Day – The number of days the applicant is holding other’s trailers or pulling trailers that are in his possession under a trailer interchange agreement
• Radius – The approximate distance (in miles) between terminals.
  

Specified Causes of Loss

Indicate the following:

• # Trailer – The number of trailers involved in the interchange agreement for the chosen coverage
• State – The states involved in the trailer interchange agreement
• # Day – The number of days the applicant is holding other’s trailers or pulling trailers that are in his possession under a trailer interchange agreement
• Radius – The approximate distance (in miles) between terminals.
  

Collision

Indicate the following:

• # Trailer – The number of trailers involved in the interchange agreement for the chosen coverage
• State – The states involved in the trailer interchange agreement
• # Day – The number of days the applicant is holding other’s trailers or pulling trailers that are in his possession under a trailer interchange agreement
• Radius – The approximate distance (in miles) between terminals.
• Deductible – For collision coverage, enter the deductible desired.
  

Hired Physical Damage

Indicate the states for which coverage is to apply. Enter the estimated number of days and number of vehicles involved. Check the applicable deductible(s) and enter the appropriate deductible amount of liability. Indicate if this coverage is on a primary or secondary basis by checking the appropriate box.

Coverage is:

Indicate if this coverage is on a primary or secondary basis by checking the appropriate box.

Other

Write in additional coverages desired, their coverage auto symbols, limits and deductibles that may be desired.

MOTOR CARRIER SECTION

Coverages

Place an “X” in the appropriate Covered auto symbols box(es) for each coverage desired. Additional information on the coverages may be found below.

Covered Auto Symbols

Truckers and Motor Carrier policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used.

Limits

For each coverage enter the limits as they are to appear on the declarations page.

Liability

Indicate if the Limit is based on a Combined Single Limit format or Split Limit format by checking either the “CSL” or “BI Ea Per” (Bodily Injury Each Person) box respectively. For CSL complete the first Limit field. For Split Limits complete the BI Each Person, BI each Accident and Property Damage Limits.

Personal Injury Protection

Refer to applicable State Manual for Options. Include any deductible selected by the applicant.

Extra P.I.P. Options

Refer to applicable State Manual for Options.

Medical Payments

Enter the appropriate Medical Payment limit.

Uninsured/Underinsured Motorists

Enter the appropriate limit(s) following the liability limit format.

Non-Truckers Hired/Borrowed Liability

Enter state(s), if any, in which autos are Hired or Borrowed

Cost of Hire

Enter the total estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is minimal, check the “If Any” box. The actual exposure will be determined at time of audit.

Hired/Borrowed Liability

Enter state(s), if any, in which trucks are Hired or Borrowed.

Cost of Hire

Enter the total estimated cost of Hire for each Hired/Borrowed coverage. If the exposure is minimal, check the “If Any” box. The actual exposure will be determined at time of audit.

Non-Owned Auto Liability

Enter state(s) where employees use their own autos in the operations of the applicant’s business.

Group Type

For Non-Owned liability, “X” all applicable group types of. Employees, Partners or Volunteer. For each group type indicated list the number of individuals involved.

Other

For additional coverages, list the coverage name, covered auto symbol and applicable limits.

Physical Damage

This section collects the coverage auto symbols for physical damage coverages.

Coverages

Place an “X” in the appropriate Covered auto symbols box(es) for each coverage desired. Additional information on the coverages may be found below.

Covered Auto Symbols

Truckers and Motor Carrier policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used.

Limits

For each coverage enter the limits as they are to appear on the declarations page.

Comprehensive / OTC

If a common deductible applies to all vehicles, enter the deductible here, or enter the individual vehicle deductibles along with the vehicle information.

Specified Causes of Loss

The Specified Cause of Loss Codes are:

• 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

Enter the deductible only if it is applicable to all vehicles.

Collision

Enter the deductible only if it is applicable to all vehicles.

Towing & Labor

This coverage is applicable only to private passenger autos.

Trailer Interchange

Comprehensive / OTC

Indicate the following:

• # Trailers- The number of trailers involved in the interchange agreement for the chosen coverage
• State- The states involved in the trailer interchange agreement
• # Day- The number of days the applicant is holding other’s trailers or pulling trailers that are in his possession under a trailer interchange agreement
• Radius- The approximate distance (in miles) between terminals.
  

Specified Causes of Loss

Indicate the following:

• # Trailer – The number of trailers involved in the interchange agreement for the chosen coverage
• State – The states involved in the trailer interchange agreement
• # Day – The number of days the applicant is holding other’s trailers or pulling trailers that are in his possession under a trailer interchange agreement
• Radius – The approximate distance (in miles) between terminals.
  

Collision

Indicate the following:

• # Trailer – The number of trailers involved in the interchange agreement for the chosen coverage
• State – The states involved in the trailer interchange agreement
• # Day – The number of days the applicant is holding other’s trailers or pulling trailers that are in his possession under a trailer interchange agreement
• Radius – The approximate distance (in miles) between terminals.
• Deductible – For collision coverage, enter the deductible desired.
  

Hired Physical Damage

Indicate the states for which coverage is to apply. Enter the estimated number of days and number of vehicles involved. Check the applicable deductible(s) and enter the appropriate deductible amount of liability. Indicate if this coverage is on a primary or secondary basis by checking the appropriate box.

Coverage is:

Indicate if this coverage is on a primary or secondary basis by checking the appropriate box.

Other

Write in additional coverages desired, their coverage auto symbols, limits and deductibles that may be desired.

ENDORSEMENTS

Enter any endorsements that apply. Be sure to include the form numbers and the required information for attaching the endorsement.

Applicant’s Signature

The applicant should read and understand the Fair Credit Reporting Act, the Privacy Act (where applicable), the Applicant’s Statement, and any other disclosure information on the form before personally signing the application.

Date

Date the form was signed.

Producer’s Signature

The producer should sign the application. This is required in most states.