ACORD 194 Instructions


ACORD 194 (2009/03) rev. 03-31-2009

Section Name Field Name Field and/or Section Description
TITLE ACORD 194 (2009/03) Truckers /Motor CarrierSupplement – Request for State / Federal Filing Action The title of the form. ACORD 194, Truckers / Motor Carrier Supplement Request For State / Federal Filing Action, is intended to supplement ACORD 132, Truckers/Motor Carrier Section, when state or federal filing action is required and the Regulation section in ACORD 132 is not adequate to provide the company with the necessary filing information. Refer to your company for any specific instructions as to company-unique requirements.
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 Named Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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 Carrier Enter text: The insurer’s full legal company name(s) as found in thefile copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Insured Identification Name (Same As On Policy) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Insured Address Enter text: The named insured’s mailing address line one.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address line two.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address city name.
IDENTIFICATION SECTION Enter code: The named insured’s mailing address state or province code.
 

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Enter code: The named insured’s mailing address postal code.
IDENTIFICATION SECTION If Name/Address On Requested Filing Should Read Differently Than Policy-Not Applicable (Checkbox) Check the box (if applicable): Indicates the name and address on requested filing should not read differently than the policy.
IDENTIFICATION SECTION If Name/Address On Requested Filing Should Read Differently Than Policy, Please Explain Enter text: The full name on the requested filing. As used here, this information is completed if the name and / or address on the requested filing should read differently than the name and address on the policy.
IDENTIFICATION SECTION Enter text: The first address line for the filing.
IDENTIFICATION SECTION Enter text: The second address line for the filing.
IDENTIFICATION SECTION Enter text: The city of the filing address.
IDENTIFICATION SECTION Enter code: The state or province of the filing address.
IDENTIFICATION SECTION Enter code: The postal code of the filing address.
IDENTIFICATION SECTION Enter text: The explanation of why the name and address requested on the filing differs from the policy.
POLICY INFORMATION Liability Policy # 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.
POLICY INFORMATION Liability Limit Enter limit: The liability limit amount. As used here, this is for the liability policy.
POLICY INFORMATION Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
POLICY INFORMATION Cargo Policy # 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.
POLICY INFORMATION Cargo Limit Enter limit: The cargo limit amount. As used here, this is for the cargo policy.
POLICY INFORMATION Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
POLICY INFORMATION IF ICC-Regulated-Base State Enter code: The base state or province of the truckers/motor carrier fleet.
TYPE OF AUTHORITY AL-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY AL-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
 

Section Name Field Name Field and/or Section Description
TYPE OF AUTHORITY AL-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY AL-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY AK-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY AK-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY AK-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY AK-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY AZ-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY AZ-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY AZ-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY AZ-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY AR-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY AR-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY AR-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY AR-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY CA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY CA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY CA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY CA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY CO-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY CO-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY CO-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY CO-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY CT-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY CT-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY CT-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY CT-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY DE-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY DE-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY DE-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY DE-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY FL-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY FL-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY FL-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY FL-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY GA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY GA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
 

Section Name Field Name Field and/or Section Description
TYPE OF AUTHORITY GA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY GA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY HI-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY HI-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY HI-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY HI-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY ID-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY ID-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY ID-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY ID-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY IL-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY IL-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY IL-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY IL-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY IN-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY IN-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY IN-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY IN-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY IA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY IA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY IA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY IA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY KS-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY KS-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY KS-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY KS-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY KY-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY KY-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY KY-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY KY-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY LA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY LA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY LA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY LA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY ME-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY ME-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
 

Section Name Field Name Field and/or Section Description
TYPE OF AUTHORITY ME-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY ME-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY MD-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY MD-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY MD-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY MD-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY MA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY MA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY MA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY MA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY MI-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY MI-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY MI-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY MI-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY MN-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY MN-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY MN-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY MN-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY MS-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY MS-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY MS-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY MS-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY MO-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY MO-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY MO-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY MO-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY MT-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY MT-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY MT-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY MT-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY NE-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY NE-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY NE-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY NE-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY NV-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY NV-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
 

Section Name Field Name Field and/or Section Description
TYPE OF AUTHORITY NV-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY NV-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY NH-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY NH-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY NH-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY NH-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY NJ-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY NJ-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY NJ-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY NJ-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY NM-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY NM-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY NM-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY NM-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY NY-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY NY-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY NY-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY NY-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY NC-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY NC-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY NC-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY NC-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY ND-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY ND-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY ND-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY ND-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY OH-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY OH-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY OH-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY OH-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY OK-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY OK-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY OK-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY OK-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY OR-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY OR-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
 

Section Name Field Name Field and/or Section Description
TYPE OF AUTHORITY OR-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY OR-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY PA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY PA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY PA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY PA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY RI-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY RI-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY RI-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY RI-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY SC-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY SC-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY SC-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY SC-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY SD-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY SD-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY SD-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY SD-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY TN-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY TN-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY TN-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY TN-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY TX-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY TX-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY TX-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY TX-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY UT-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY UT-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY UT-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY UT-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY VT-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY VT-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY VT-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY VT-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY VA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY VA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
 

Section Name Field Name Field and/or Section Description
TYPE OF AUTHORITY VA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY VA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY WA-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY WA-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY WA-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY WA-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY WV-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY WV-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY WV-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY WV-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY WI-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY WI-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY WI-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY WI-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY WY-Liability-I (Checkbox) Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY WY-Liability-E (Checkbox) Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY WY-Cargo-I (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY WY-Cargo-E (Checkbox) Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY For ICC Filings: Liability MC # Enter identifier: The liability MC number for ICC filings.
TYPE OF AUTHORITY For ICC Filings: Cargo MC # Enter identifier: The cargo MC number for ICC filings.
TYPE OF AUTHORITY Canadian Province(s) Enter text: The description of the type of filing authority for Canadian provinces.
TYPE OF AUTHORITY Oversize / Overweight Certificate(s) Enter text: The description of any certificates for oversize / overweight cargo.
TYPE OF CHANGE New (Checkbox) Check the box (if applicable): Indicates this is a request for a new filing.
TYPE OF CHANGE Renewal (Checkbox) Check the box (if applicable): Indicates this is a request for a renewal of a previous filing.
TYPE OF CHANGE Cancellation (Checkbox) Check the box (if applicable): Indicates that a previous filing should be cancelled.
TYPE OF CHANGE Other (Checkbox) Check the box (if applicable): Indicates a request for a filing or a change to a filing other than the options listed.
TYPE OF CHANGE Other Description Check the box (if applicable): The description of the type of filing or change to a previous filing being requested.
REMARKS Remarks Enter text: The general remarks associated with the truckers / motor carrier request for state / federal filing action.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).