ACORD 137 RI (2014/12) - RHODE ISLAND COMMERCIAL AUTO COVERAGES / LIMITS SECTION

ACORD 137 RI (2014/12) - RHODE ISLAND COMMERCIAL AUTO COVERAGES / LIMITS SECTION
ACORD 137 RI, Rhode Island Commercial Auto, Coverages / 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 Carriers Section.
The following are the specific differences in this state:
* Personal Injury Protection coverages are not available; this is not a no-fault state.
* Uninsured and Underinsured Motorist coverages are combined.
* A state-specific fraud warning is included.
* Statements are added to the form that:
1. Allow the applicant to acknowledge the offer of Medical Payments coverage, and the options selected;
2. Reference the state supplement, ACORD 61 RI, which must be signed by the applicant if Uninsured / Underinsured Motorists Bodily Injury
coverage is rejected;
3. Allow the applicant to acknowledge the offer of Uninsured / Underinsured Motorists Property Damage coverage, and the options selected.
* The applicant must initial the options selected.
Form Page 1
Section Name
Field Name
Description
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 date on which the form is completed.
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 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
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 1 of 22
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file 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 Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO
Other 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 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
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 2 of 22
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 / Underinsured
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 (BI Only) Ea Acc
Check the box (if applicable): Indicates uninsured / underinsured combined single limit bodily
injury only option has been selected.
BUSINESS AUTO
Limit
Enter limit: The uninsured / underinsured motorists combined single limit per accident amount.
The use of this limit varies by state.
BUSINESS AUTO
CSL (BI PD) Ea Acc
Check the box (if applicable): Indicates uninsured / underinsured combined single limit bodily
injury and property damage option has been selected.
BUSINESS AUTO
Limit
Enter limit: The uninsured / underinsured motorists combined single limit per accident amount.
The use of this limit varies by state.
BUSINESS AUTO
BI Ea Per
Check the box (if applicable): Indicates uninsured / underinsured bodily injury option has been
selected.
BUSINESS AUTO
Limit
Enter limit: The uninsured / underinsured motorists bodily injury per person limit. The use of this
limit varies by state. On commercial policies, this may contain the combined single limit per
accident amount.
BUSINESS AUTO
BI Ea Acc
Enter limit: The uninsured / underinsured motorists bodily injury per accident limit (in some
states this may contain the uninsured / underinsured motorists combined single limit per
accident limit). The use of this limit varies by state.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 3 of 22
BUSINESS AUTO
PD
Check the box (if applicable): Indicates uninsured / underinsured property damage option has
been selected.
BUSINESS AUTO
Ea Acc
Enter limit: The uninsured / underinsured property damage limit amount.
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 4 of 22
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 5 of 22
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 6 of 22
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
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. ACORD 101, Additional Remarks Schedule, may be attached if
more space is required.
ENDORSEMENTS /
REMARKS
Medical Payments Coverage
- Select
Initial here: The named insured's initials. As used here, indicates the named insured has
selected medical payments coverage as listed in the application.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 7 of 22
ENDORSEMENTS /
REMARKS
Reject
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected medical payments coverage in its entirety.
ENDORSEMENTS /
REMARKS
UM/UIM Coverage - Select
PD
Initial here: The named insured's initials. As used here, indicates the named insured has
selected uninsured/underinsured motorists bodily injury coverage at the limits shown in the
application.
ENDORSEMENTS /
REMARKS
Select BI
Initial here: The named insured's initials. As used here, indicates the named insured has
selected uninsured/underinsured motorists property damage coverage at the limits shown in the
application.
ENDORSEMENTS /
REMARKS
Reject PD
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected uninsured/underinsured motorists property damage coverage.
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.) of the company(ies) listed on the document. 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.
Form Page 2
Section Name
Field Name
Description
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 8 of 22
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
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 / Underinsured
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 (BI Only) Ea Acc
Check the box (if applicable): Indicates uninsured / underinsured combined single limit bodily
injury only option has been selected.
TRUCKERS
Limit
Enter limit: The uninsured / underinsured motorists combined single limit per accident amount.
The use of this limit varies by state.
TRUCKERS
CSL (BI PD) Ea Acc
Check the box (if applicable): Indicates uninsured / underinsured combined single limit bodily
injury and property damage option has been selected.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 9 of 22
TRUCKERS
Limit
Enter limit: The uninsured / underinsured motorists combined single limit per accident amount.
The use of this limit varies by state.
TRUCKERS
BI Ea Per
Check the box (if applicable): Indicates uninsured / underinsured bodily injury option has been
selected.
TRUCKERS
Limit
Enter limit: The uninsured / underinsured motorists bodily injury per person limit. The use of this
limit varies by state. On commercial policies, this may contain the combined single limit per
accident amount.
TRUCKERS
BI Ea Acc
Enter limit: The uninsured / underinsured motorists bodily injury per accident limit (in some
states this may contain the uninsured / underinsured motorists combined single limit per
accident limit). The use of this limit varies by state.
TRUCKERS
PD
Check the box (if applicable): Indicates uninsured / underinsured property damage option has
been selected.
TRUCKERS
Ea Acc
Enter limit: The uninsured / underinsured property damage limit amount.
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
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. Check this box if the
exposure is minimal. The actual exposure is determined at the time of audit.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 10 of 22
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 11 of 22
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 12 of 22
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 13 of 22
TRUCKERS
Collision - 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
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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 14 of 22
ENDORSEMENTS /
REMARKS
Endorsements
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. ACORD 101, Additional Remarks Schedule, may be attached if
more space is required.
ENDORSEMENTS /
REMARKS
Medical Payments Coverage
- Select
Initial here: The named insured's initials. As used here, indicates the named insured has
selected medical payments coverage as listed in the application.
ENDORSEMENTS /
REMARKS
Reject
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected medical payments coverage in its entirety.
ENDORSEMENTS /
REMARKS
UM/UIM Coverage - Select
PD
Initial here: The named insured's initials. As used here, indicates the named insured has
selected uninsured/underinsured motorists bodily injury coverage at the limits shown in the
application.
ENDORSEMENTS /
REMARKS
Select BI
Initial here: The named insured's initials. As used here, indicates the named insured has
selected uninsured/underinsured motorists property damage coverage at the limits shown in the
application.
ENDORSEMENTS /
REMARKS
Reject PD
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected uninsured/underinsured motorists property damage coverage.
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.) of the company(ies) listed on the document. 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.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
MOTOR CARRIER SECTION
Liability - 61
Check the box (if applicable): Indicates that any auto is covered.
MOTOR CARRIER SECTION
62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION
63
Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER SECTION
64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION
67
Check the box (if applicable): Indicates that specifically described autos are covered.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 15 of 22
MOTOR CARRIER SECTION
68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION
71
Check the box (if applicable): Indicates that non-owned autos only are covered.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
MOTOR CARRIER SECTION
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 SECTION
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 SECTION
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 SECTION
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 SECTION
Medical Payments - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION
63
Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER SECTION
64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION
67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Each Person
Enter limit: The medical payments per person limit.
MOTOR CARRIER SECTION
Uninsured / Underinsured
Motorists - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION
63
Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER SECTION
64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION
66
Check the box (if applicable): Indicates that owned autos subject to a compulsory uninsured
motorist law are covered.
MOTOR CARRIER SECTION
67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 16 of 22
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
CSL (BI Only) Ea Acc
Check the box (if applicable): Indicates uninsured / underinsured combined single limit bodily
injury only option has been selected.
MOTOR CARRIER SECTION
Limit
Enter limit: The uninsured / underinsured motorists combined single limit per accident amount.
The use of this limit varies by state.
MOTOR CARRIER SECTION
CSL (BI PD) Ea Acc
Check the box (if applicable): Indicates uninsured / underinsured combined single limit bodily
injury and property damage option has been selected.
MOTOR CARRIER SECTION
Limit
Enter limit: The uninsured / underinsured motorists combined single limit per accident amount.
The use of this limit varies by state.
MOTOR CARRIER SECTION
BI Ea Per
Check the box (if applicable): Indicates uninsured / underinsured bodily injury option has been
selected.
MOTOR CARRIER SECTION
Limit
Enter limit: The uninsured / underinsured motorists bodily injury per person limit. The use of this
limit varies by state. On commercial policies, this may contain the combined single limit per
accident amount.
MOTOR CARRIER SECTION
BI Ea Acc
Enter limit: The uninsured / underinsured motorists bodily injury per accident limit (in some
states this may contain the uninsured / underinsured motorists combined single limit per
accident limit). The use of this limit varies by state.
MOTOR CARRIER SECTION
PD
Check the box (if applicable): Indicates uninsured / underinsured property damage option has
been selected.
MOTOR CARRIER SECTION
Ea Acc
Enter limit: The uninsured / underinsured property damage limit amount.
MOTOR CARRIER SECTION
Non-Truckers Hired /
Borrowed Liability - Yes
Check the box (if applicable): Indicates if hired / borrowed coverage applies.
MOTOR CARRIER SECTION
States
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
No
Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
MOTOR CARRIER SECTION
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
MOTOR CARRIER SECTION
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 SECTION
Truckers Hired / Borrowed
Liability - Yes
Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies.
MOTOR CARRIER SECTION
States
Enter code: Indicates a state where autos are hired or borrowed.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 17 of 22
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
No
Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not apply.
MOTOR CARRIER SECTION
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
MOTOR CARRIER SECTION
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 SECTION
Non-Owned Auto Liability -
Yes
Check the box (if applicable): Indicates if non-owned coverage applies.
MOTOR CARRIER SECTION
States
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
No
Check the box (if applicable): Indicates that non-owned coverage does not apply.
MOTOR CARRIER SECTION
Group Type - Employees
Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees.
MOTOR CARRIER SECTION
Number Of Employees
Enter number: The number of employees that use their own automobiles.
MOTOR CARRIER SECTION
Volunteers
Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers.
MOTOR CARRIER SECTION
Number Of Volunteers
Enter number: The number of volunteers that use their own automobiles.
MOTOR CARRIER SECTION
Partners
Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners.
MOTOR CARRIER SECTION
Number Of Partners
Enter number: The number of partners that use their own automobiles.
MOTOR CARRIER SECTION
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 SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 18 of 22
MOTOR CARRIER SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
MOTOR CARRIER SECTION
COMP / OTC - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION
63
Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER SECTION
64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION
67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION
68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
MOTOR CARRIER SECTION
Specified Causes of Loss -
62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION
63
Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER SECTION
64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION
67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION
68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
SCL
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
MOTOR CARRIER SECTION
F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
MOTOR CARRIER SECTION
FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
MOTOR CARRIER SECTION
FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on
this vehicle.
MOTOR CARRIER SECTION
LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on
this vehicle.
MOTOR CARRIER SECTION
Deductible
Enter deductible: The deductible associated with specified causes of loss coverage.
MOTOR CARRIER SECTION
Collision - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION
63
Check the box (if applicable): Indicates that owned private passenger autos only are covered.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 19 of 22
MOTOR CARRIER SECTION
64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION
67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION
68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Deductible
Enter deductible: The collision deductible amount.
MOTOR CARRIER SECTION
Towing & Labor - 63
Check the box (if applicable): Indicates that owned private passenger autos only are covered.
MOTOR CARRIER SECTION
67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Limit
Enter limit: The towing and labor limit amount.
MOTOR CARRIER SECTION
COMP / OTC - 69
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
MOTOR CARRIER SECTION
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 SECTION
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
MOTOR CARRIER SECTION
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER SECTION
# 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 SECTION
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy, are
pulled by other tractors.
MOTOR CARRIER SECTION
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 SECTION
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 SECTION
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 20 of 22
MOTOR CARRIER SECTION
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER SECTION
# 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 SECTION
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy, are
pulled by other tractors.
MOTOR CARRIER SECTION
Collision - 69
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
MOTOR CARRIER SECTION
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 SECTION
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
MOTOR CARRIER SECTION
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER SECTION
# 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 SECTION
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy, are
pulled by other tractors.
MOTOR CARRIER SECTION
Deductible
Enter deductible: The deductible amount applicable to trailer interchange collision coverage.
MOTOR CARRIER SECTION
Hired Physical Damage -
States
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
# Days
Enter number: The number of days needed to rate Hired Physical Damage Coverage.
MOTOR CARRIER SECTION
# Veh
Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
MOTOR CARRIER SECTION
Coverage is: - Primary
Check the box (if applicable): Indicates if this coverage is on a primary basis.
MOTOR CARRIER SECTION
Secondary
Check the box (if applicable): Indicates if this coverage is on a secondary basis.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 21 of 22
MOTOR CARRIER SECTION
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 SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
MOTOR CARRIER SECTION
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. ACORD 101, Additional Remarks Schedule, may be attached if
more space is required.
SIGNATURE
Medical Payments Coverage
- Select
Initial here: The named insured's initials. As used here, indicates the named insured has
selected medical payments coverage as listed in the application.
SIGNATURE
Reject
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected medical payments coverage in its entirety.
SIGNATURE
UM/UIM Coverage - Select
PD
Initial here: The named insured's initials. As used here, indicates the named insured has
selected uninsured/underinsured motorists bodily injury coverage at the limits shown in the
application.
SIGNATURE
Select BI
Initial here: The named insured's initials. As used here, indicates the named insured has
selected uninsured/underinsured motorists property damage coverage at the limits shown in the
application.
SIGNATURE
Reject PD
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected uninsured/underinsured motorists property damage coverage.
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.) of the company(ies) listed on the document. 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.
ACORD 137 RI (2014/12) rev. 02-27-2014
Page 22 of 22