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.