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ACORD 22 (2007/02) rev. 09-04-2008
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Section Name |
Field Name |
Field and/or Section Description |
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Use ACORD 22, Intermodal Interchange Certificate of Insurance, to provide a coverage statement to the Intermodal Association of North America (IANA) when coverage being provided includes the Truckers Uniform Intermodal Interchange Endorsement (Form UIIE1 or CA-23-17 equivalent). |
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IMPORTANT |
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Kansas, Kentucky, Minnesota, Missouri, North Carolina, Oklahoma and Wisconsin require the filing of certificate of insurance forms. ACORD has filed all of its certificates in these states. In these states, the text of ACORD's certificates cannot be modified, unless the modified form is filed for approval by the respective state Department of Insurance. |
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TITLE ACORD 22 (2007/02) |
Intermodal Interchange Certificate of Insurance |
Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved. In these states, this form can only be changed to reflect the terms and conditions of the policy on which it is reporting. Such change(s) must be approved in advance by the insurance carrier that issued such policy. |
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IDENTIFICATION SECTION |
Date |
Month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Agency's name and address. |
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IDENTIFICATION SECTION |
Insured |
Insured’s name and address as they appear on the policy declarations page. |
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This section is designed for use in certifying coverage issued by many as five companies. |
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INSURERS AFFORDING |
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Enter only full legal company name(s) as found in the file copy of the policy. Do not enter |
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COVERAGE |
Company A |
group or trade names. |
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This section is designed for use in certifying coverage issued by many as five companies. |
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INSURERS AFFORDING |
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Enter only full legal company name(s) as found in the file copy of the policy. Do not enter |
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COVERAGE |
Company B |
group or trade names. |
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This section is designed for use in certifying coverage issued by many as five companies. |
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INSURERS AFFORDING |
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Enter only full legal company name(s) as found in the file copy of the policy. Do not enter |
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COVERAGE |
Company C |
group or trade names. |
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This section is designed for use in certifying coverage issued by many as five companies. |
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INSURERS AFFORDING |
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Enter only full legal company name(s) as found in the file copy of the policy. Do not enter |
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COVERAGE |
Company D |
group or trade names. |
ACORD 22 (2007/02) rev. 09-04-2008
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Section Name |
Field Name |
Field and/or Section Description |
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This section is designed for use in certifying coverage issued by many as five companies. |
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INSURERS AFFORDING |
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Enter only full legal company name(s) as found in the file copy of the policy. Do not enter |
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COVERAGE |
Company E |
group or trade names. |
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NAIC # |
NAIC # |
Enter the NAIC number for each insurer affording coverage. |
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BEST RATING |
Best Rating |
Enter the rating assigned to the company by A.M. Best. |
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Enter the Company Letter of the company, as identified in the Insurers Affording Coverage |
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COVERAGE INFORMATION |
Insr Ltr |
section, next to the appropriate coverage(s). |
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COVERAGE INFORMATION |
Add'l Insrd |
Use this column if the certificate holder has been named as an additional insured for any of the coverages described in the certificate. Place a check mark next to each coverage where an additional insured endorsement has been issued. |
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Type of Insurance - General |
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COVERAGE INFORMATION |
Liability |
Complete this section if you are certifying general liability coverage. |
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Check this box for Commercial General Liability (CGL) and one of the corresponding |
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COVERAGE INFORMATION |
Commercial General Liability |
boxes to designate the type of policy issued, Claims Made, or Occurrence (Occur). |
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COVERAGE INFORMATION |
Other General Liability Coverages |
The two open option boxes available allow listing of liability coverages not found on this form. List the coverage type next to the available box. An example of this would be issuing a certificate for Comprehensive Personal Liability. The first box would be checked and "Comprehensive Personal Liability" would be inserted on the line after the box. |
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General Aggregate Limit Applies |
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COVERAGE INFORMATION |
Per Policy |
Check this box if the general aggregate limit applies per policy. |
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General Aggregate Limit Applies |
Check this box if the general aggregate limit applies other than per policy, (e.g., per |
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COVERAGE INFORMATION |
Per |
project, or per location). |
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COVERAGE INFORMATION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
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Policy Effective Date |
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COVERAGE INFORMATION |
(MM/DD/YYYY) |
Date on which the terms and conditions of the policy commence. |
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Policy Expiration Date |
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COVERAGE INFORMATION |
(MM/DD/YYYY) |
Date on which the terms and conditions of the policy expires. |
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All limits should be listed as whole dollar amounts. Enter limits corresponding to those |
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found on the policy declarations page. Any questions about appropriate limits or |
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COVERAGE INFORMATION |
Limits |
applicable policy coverage(s) should be answered by the issuing insurer(s). |
ACORD 22 (2007/02) rev. 09-04-2008
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Section Name |
Field Name |
Field and/or Section Description |
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Type of Insurance - Automobile Liability |
Complete this section only if you are certifying automobile liability. Check all appropriate boxes to correspond with the covered auto symbols found on the policy declarations page. The last available option box allows listing an automobile liability coverage not found on this form. List the coverage type next to this optional box. If the certificate is being issued to the owner of a leased vehicle, DO NOT USE THIS FORM. Use ACORD 23, Leased Auto Certificate of Insurance. |
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COVERAGE INFORMATION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
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COVERAGE INFORMATION |
Policy Effective Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy commence. |
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COVERAGE INFORMATION |
Policy Expiration Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy expires. |
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COVERAGE INFORMATION |
Limits |
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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COVERAGE INFORMATION |
Type of Insurance - Cargo |
Complete this section only if you are certifying Cargo Coverage. |
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COVERAGE INFORMATION |
Per Vehicle Ded |
Enter the deductible amount per vehicle. |
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COVERAGE INFORMATION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
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COVERAGE INFORMATION |
Policy Effective Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy commence. |
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COVERAGE INFORMATION |
Policy Expiration Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy expires. |
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COVERAGE INFORMATION |
Limits |
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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COVERAGE INFORMATION |
Type of Insurance - Trailer Interchange Physical Damage |
Complete this section only if you are certifying Trailer Interchange Physical Damage Coverage. |
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COVERAGE INFORMATION |
Per Trailer Ded |
Enter the deductible amount per trailer. |
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COVERAGE INFORMATION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
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COVERAGE INFORMATION |
Policy Effective Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy commence. |
ACORD 22 (2007/02) rev. 09-04-2008
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Section Name |
Field Name |
Field and/or Section Description |
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COVERAGE INFORMATION |
Policy Expiration Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy expires. |
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COVERAGE INFORMATION |
Limits |
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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COVERAGE INFORMATION |
Type of Insurance -Excess/Umbrella Liability |
Complete this section only if you are certifying some type of excess or umbrella liability policy. Check the appropriate box to indicate whether the "coverage trigger" is on a claims-made or an occurrence basis. Also show any deductible or retention amount. |
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COVERAGE INFORMATION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
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COVERAGE INFORMATION |
Policy Effective Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy commence. |
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COVERAGE INFORMATION |
Policy Expiration Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy expires. |
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COVERAGE INFORMATION |
Limits |
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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COVERAGE INFORMATION |
Type of Insurance - Workers Compensation and Employers' Liability |
If workers compensation coverage is based on statutory limits, check the appropriate box within the limit section. If other limits apply, check the appropriate box and show the limits in the "Other" section. If Employer's Liability is to be certified, show the limits applicable to "Each Accident", "Disease-Each Employee" and "Disease-Policy Limit". |
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COVERAGE INFORMATION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
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COVERAGE INFORMATION |
Policy Effective Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy commence. |
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COVERAGE INFORMATION |
Policy Expiration Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy expires. |
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COVERAGE INFORMATION |
Limits |
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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COVERAGE INFORMATION |
Type of Insurance - Other |
This section certifies other coverages that are not listed on the form. The type of insurance, policy number, policy effective date, policy expiration date and limits sections should be completed. |
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Section Name |
Field Name |
Field and/or Section Description |
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COVERAGE INFORMATION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
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COVERAGE INFORMATION |
Policy Effective Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy commence. |
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COVERAGE INFORMATION |
Policy Expiration Date (MM/DD/YYYY) |
Date on which the terms and conditions of the policy expires. |
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COVERAGE INFORMATION |
Limits |
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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COVERAGE INFORMATION |
Description of Operations / Locations / Vehicles / Exclusions Added by Endorsement / Special Provisions |
Record information necessary to identify the operations, locations or vehicles for which the certificate was issued. Any exclusion endorsement or special policy conditions should also be indicated. Information about additional insureds should also be shown here. However, if it is necessary to show several additional insureds for liability coverages (e.g., mortgagees, vendors, landlords, etc.), and there is not enough room on the form, use the Descriptions box to indicate "see Additional Interest form, ACORD 45, attached" and use ACORD 45 to show the information pertinent to the additional insureds. |
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COVERAGE INFORMATION |
Truckers Uniform Intermodal Interchange Endorsement check box |
Check this box if the Truckers Uniform Intermodal Interchange Endorsement is a part of the policy(ies). Attach a list of providers that are additional insureds in regards to auto liability. Also indicate with a single asterisk (*) those providers that are additional insureds for general liability and a double asterisk (**) for those that are additional insureds on trailer interchange coverage. |
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CERTIFICATE HOLDER |
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This Certificate should be sent only to the President of The Intermodal Association of North America. |
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CANCELLATION |
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Number of days in which the company will endeavor to mail a written cancellation notice. This amount is subject to approval by the company(ies). |
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CANCELLATION |
Authorized Representative |
Form must be signed by an agent, broker, or other representative authorized by all companies to issue Certificates. |
ACORD 22 (2007/02) rev. 09-04-2008
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