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ACORD Form 138 LA Louisiana Garage and Dealers Instructions

 

 
ACORD 138 LA (2009/01) rev. 03-27-2009 1 of 11
Section Name Field Name Field and/or Section Description
The title of the form. ACORD 138 LA, Louisiana Garage and Dealers Coverages / Limits Section, is used to collect the coverage and limit information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 128, Garage and Dealers Section.
The following are the specific differences in this state.
* Personal Injury Protection coverages are not available; this is not a "no-fault" state.
* Underinsured Motorists coverage is included in Uninsured Motorist coverage.
TITLE ACORD 138 LA (2009/01) Louisiana Garage and Dealers, Coverages / Limits Section * State specific fraud warning * State of Louisiana UMBI / PD Auto supplement is part of the application.
Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION Agency Customer ID 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.
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
IDENTIFICATION SECTION Policy Number required for self-insurance, the self-insured license or contract number.
Enter date: The effective date of the policy. The date that the terms and conditions of the
IDENTIFICATION SECTION Effective Date policy commence.
IDENTIFICATION SECTION Named Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
IDENTIFICATION SECTION Carrier 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.

ACORD 138 LA (2009/01) rev. 03-27-2009 2 of 11

Section Name Field Name Field and/or Section Description
COVERAGES / LIMITS Liability 21 Check the box (if applicable): Indicates any auto is covered. As used here, Garage or Dealers policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to check the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used. Symbols 21 through 26 provide fleet automatic coverage. Symbol 21 includes Hired and Non-Owned auto coverage. If symbol 21 is not used and Hired Auto (symbol 28) or Non-Owned Auto (symbol 29) coverage is desired, those symbols must be checked. The symbols indicate the automobiles to which each coverage applies. The symbol "triggers"" the coverage. For exact policy definitions of the symbols, please refer to the company's policy declarations page.
COVERAGES / LIMITS Liability 22 Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS Liability 23 Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS Liability 24 Check the box (if applicable): Indicates owned autos other than private passenger autos are covered.
COVERAGES / LIMITS Liability 27 Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS Liability 28 Check the box (if applicable): Indicates only hired autos are covered.
COVERAGES / LIMITS Liability 29 Check the box (if applicable): Indicates non-owned autos used in garage business are covered.
COVERAGES / LIMITS Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS 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.
COVERAGES / LIMITS EA ACC ($) Auto Only Enter limit: The liability each accident limit for garage operations auto only. For Dealers, use this field to enter the Policy Combined Single Limit.
COVERAGES / LIMITS Other Than Auto Only ($) Enter limit: The liability each accident limit for garage operations other than auto only.
COVERAGES / LIMITS Aggregate ($) Enter limit: The liability aggregate limit for garage operations other than auto only.
COVERAGES / LIMITS Dealers Only-Limited Check the box (if applicable): Indicates the liability coverage is limited for dealers.
COVERAGES / LIMITS Dealers Only-Unlimited Check the box (if applicable): Indicates the liability coverage is unlimited for dealers.
COVERAGES / LIMITS Medical Payments 21 Check the box (if applicable): Indicates any auto is covered.
COVERAGES / LIMITS Medical Payments 22 Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS Medical Payments 23 Check the box (if applicable): Indicates only owned private passengers autos are covered.
ACORD 138 LA (2009/01) rev. 03-27-2009 3 of 11
Section Name Field Name Field and/or Section Description
COVERAGES / LIMITS Medical Payments 24 Check the box (if applicable): Indicates owned autos other than private passenger autos are covered.
COVERAGES / LIMITS Medical Payments 27 Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS Medical Payments 28 Check the box (if applicable): Indicates only hired autos are covered.
COVERAGES / LIMITS Medical Payments 29 Check the box (if applicable): Indicates non-owned autos used in garage business are covered.
COVERAGES / LIMITS Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS Other Covered Auto Symbol Description Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or enter a company-unique symbol if applicable.
COVERAGES / LIMITS Limit ($) Enter limit: The medical payments per person limit.
COVERAGES / LIMITS Automobile (Checkbox) Check the box (if applicable): Indicates the policy coverage includes automobile. Note that automobile and premises operations coverages can apply.
COVERAGES / LIMITS Prem Operations (Checkbox) Check the box (if applicable): Indicates the policy coverage includes premises operations. Note that both automobile and premises operations coverages can apply.
COVERAGES / LIMITS Uninsured Motorist 22 Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS Uninsured Motorist 23 Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS Uninsured Motorist 24 Check the box (if applicable): Indicates owned autos other than private passenger autos are covered.
COVERAGES / LIMITS Uninsured Motorist 26 Check the box (if applicable): Indicates owned autos subject to uninsured motorists law are covered.
COVERAGES / LIMITS Uninsured Motorist 27 Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS 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.
COVERAGES / LIMITS Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS Uninsured Motorists-Economic & Non Economic Losses (Checkbox) Check the box (if applicable): Indicates the uninsured motorists coverage economic and non-economic losses option has been selected.
COVERAGES / LIMITS Economic Losses Only (Checkbox) Check the box (if applicable): Indicates the uninsured motorists coverage economic losses only option has been selected.
COVERAGES / LIMITS CSL (Checkbox) Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage.

ACORD 138 LA (2009/01) rev. 03-27-2009 4 of 11

Section Name Field Name Field and/or Section Description
COVERAGES / LIMITS BI EA PER (Checkbox) Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage.
COVERAGES / LIMITS Amount Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.)
COVERAGES / LIMITS BI Each Accident ($) Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
COVERAGES / LIMITS Property Damage ($) Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
COVERAGES / LIMITS 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).
COVERAGES / LIMITS Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
COVERAGES / LIMITS Additional Coverage Limit Enter limit: The limit amount of the other coverage.
PHYSICAL DAMAGE Comp / OTC Check the box (if applicable): Indicates the physical damage is comprehensive/other than collision.
PHYSICAL DAMAGE Specified Perils Check the box (if applicable): Indicates the physical damage coverage is for specified perils.
PHYSICAL DAMAGE Perils option field Enter text: The codes associated with specified perils coverage. The codes are: F - Fire, F&T - Fire and Theft, FTW - Fire, Theft and Wind, LSP - Limited Specified Perils, SP -Specified Perils.
PHYSICAL DAMAGE Specified Perils 22 Check the box (if applicable): Indicates all owned autos are covered.
PHYSICAL DAMAGE Specified Perils 23 Check the box (if applicable): Indicates only owned private passengers autos are covered.
PHYSICAL DAMAGE Specified Perils 24 Check the box (if applicable): Indicates owned autos other than private passenger autos are covered.
PHYSICAL DAMAGE Specified Perils 27 Check the box (if applicable): Indicates specifically described autos are covered.
PHYSICAL DAMAGE Specified Perils 28 Check the box (if applicable): Indicates only hired autos are covered.
PHYSICAL DAMAGE Specified Perils 31 Check the box (if applicable): Indicates autos on consignment and dealer autos are covered.
PHYSICAL DAMAGE Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
PHYSICAL DAMAGE 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 138 LA (2009/01) rev. 03-27-2009 5 of 11
Section Name Field Name Field and/or Section Description
PHYSICAL DAMAGE LOC # One Enter number: The producer assigned number for the location.
PHYSICAL DAMAGE Enter the Limits for Each Location One Enter limit: The physical damage comprehensive/other than collision or specified perils limit amount.
PHYSICAL DAMAGE Deductible Per Auto One Enter deductible: The physical damage comprehensive/other than collision or specified perils per auto deductible amount.
PHYSICAL DAMAGE Maximum Deductible Per Loss One Enter deductible: The physical damage comprehensive/other than collision or specified perils maximum deductible per loss amount.
PHYSICAL DAMAGE LOC # Two Enter number: The producer assigned number for the location.
PHYSICAL DAMAGE Enter the Limits for Each Location Two Enter limit: The physical damage comprehensive/other than collision or specified perils limit amount.
PHYSICAL DAMAGE Deductible Per Auto Two Enter deductible: The physical damage comprehensive/other than collision or specified perils per auto deductible amount.
PHYSICAL DAMAGE Maximum Deductible Per Loss Two Enter deductible: The physical damage comprehensive/other than collision or specified perils maximum deductible per loss amount.
PHYSICAL DAMAGE LOC # Three Enter number: The producer assigned number for the location.
PHYSICAL DAMAGE Enter the Limits for Each Location Three Enter limit: The physical damage comprehensive/other than collision or specified perils limit amount.
PHYSICAL DAMAGE Deductible Per Auto Three Enter deductible: The physical damage comprehensive/other than collision or specified perils per auto deductible amount.
PHYSICAL DAMAGE Maximum Deductible Per Loss Three Enter deductible: The physical damage comprehensive/other than collision or specified perils maximum deductible per loss amount.
PHYSICAL DAMAGE Collision 22 Check the box (if applicable): Indicates all owned autos are covered.
PHYSICAL DAMAGE Collision 23 Check the box (if applicable): Indicates only owned private passengers autos are covered.
PHYSICAL DAMAGE Collision 24 Check the box (if applicable): Indicates owned autos other than private passenger autos are covered.
PHYSICAL DAMAGE Collision 27 Check the box (if applicable): Indicates specifically described autos are covered.
PHYSICAL DAMAGE Collision 28 Check the box (if applicable): Indicates only hired autos are covered.
PHYSICAL DAMAGE Collision 31 Check the box (if applicable): Indicates autos on consignment and dealer autos are covered.
PHYSICAL DAMAGE Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
PHYSICAL DAMAGE 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.
PHYSICAL DAMAGE Collision-Deductible ($) Enter deductible: The physical damage collision deductible amount.

ACORD 138 LA (2009/01) rev. 03-27-2009 6 of 11

Section Name Field Name Field and/or Section Description
PHYSICAL DAMAGE 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).
PHYSICAL DAMAGE Additional Coverage Covered Auto Symbols Enter text: The symbols that apply to the other coverage listed.
PHYSICAL DAMAGE Additional Coverage Limit Enter limit: The limit amount of the other coverage.
GARAGE KEEPERS Legal Liability Check the box (if applicable): Indicates the policy is to be written on a legal liability basis.
GARAGE KEEPERS Direct Basis Check the box (if applicable): Indicates the policy is to be written on a direct basis.
GARAGE KEEPERS Primary Check the box (if applicable): Indicates this policy is the primary coverage.
GARAGE KEEPERS Excess Check the box (if applicable): Indicates this policy is for excess coverage.
GARAGE KEEPERS Comp / OTC Check the box (if applicable): Indicates the garage keepers coverage is comprehensive/other than collision.
GARAGE KEEPERS Specified Perils Check the box (if applicable): Indicates the garage keepers coverage is for specified perils.
GARAGE KEEPERS Perils option field Enter text: The codes associated with specified perils coverage. The codes are: F - Fire, F&T - Fire and Theft, FTW - Fire, Theft and Wind, LSP - Limited Specified Perils, SP -Specified Perils.
GARAGE KEEPERS 30 (Checkbox) Check the box (if applicable): Indicates autos left for service, repairs and/or storage are covered.
GARAGE KEEPERS Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
GARAGE KEEPERS 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.
GARAGE KEEPERS LOC # One Enter number: The producer assigned number for the location. 'The location number for the physical damage coverages should correspond to a location number documented on the ACORD 125.
GARAGE KEEPERS Enter the Limits for Each Location One Enter limit: The garage keepers comprehensive/other than collision or specified perils limit amount.
GARAGE KEEPERS # of Autos One Enter number: The number of vehicles located on the premises.
GARAGE KEEPERS Deductible Per Auto One Enter deductible: The garage keepers comprehensive/other than collision or specified perils per auto deductible amount.
GARAGE KEEPERS Maximum Deductible Per Loss One Enter deductible: The garage keepers comprehensive/other than collision or specified perils maximum deductible per loss amount.

ACORD 138 LA (2009/01) rev. 03-27-2009 7 of 11

Section Name Field Name Field and/or Section Description
GARAGE KEEPERS LOC # Two Enter number: The producer assigned number for the location. 'The location number for the physical damage coverages should correspond to a location number documented on the ACORD 125.
GARAGE KEEPERS Enter the Limits for Each Location Two Enter limit: The garage keepers comprehensive/other than collision or specified perils limit amount.
GARAGE KEEPERS # of Autos Two Enter number: The number of vehicles located on the premises.
GARAGE KEEPERS Deductible Per Auto Two Enter deductible: The garage keepers comprehensive/other than collision or specified perils per auto deductible amount.
GARAGE KEEPERS Maximum Deductible Per Loss Two Enter deductible: The garage keepers comprehensive/other than collision or specified perils maximum deductible per loss amount.
GARAGE KEEPERS LOC # Three Enter number: The producer assigned number for the location. 'The location number for the physical damage coverages should correspond to a location number documented on the ACORD 125.
GARAGE KEEPERS Enter the Limits for Each Location Three Enter limit: The garage keepers comprehensive/other than collision or specified perils limit amount.
GARAGE KEEPERS # of Autos Three Enter number: The number of vehicles located on the premises.
GARAGE KEEPERS Deductible Per Auto Three Enter deductible: The garage keepers comprehensive/other than collision or specified perils per auto deductible amount.
GARAGE KEEPERS Maximum Deductible Per Loss Three Enter deductible: The garage keepers comprehensive/other than collision or specified perils maximum deductible per loss amount.
GARAGE KEEPERS 30 (checkbox) Two Check the box (if applicable): Indicates autos left for service, repairs and/or storage are covered.
GARAGE KEEPERS Other Covered Auto Symbol Check the box (if applicable): Indicates that a symbol other than those listed should be used.
GARAGE KEEPERS 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.
GARAGE KEEPERS LOC # Four Enter number: The producer assigned number for the location. The location number for the garage keepers coverages should correspond to a location number documented on the ACORD 125.
GARAGE KEEPERS Enter the Limits for Each Location Four Enter limit: The garage keepers collision limit amount.
GARAGE KEEPERS # of Autos Four Enter number: The number of vehicles located on the premises.
GARAGE KEEPERS Deductible Per Auto Four Enter deductible: The garage keepers collision per auto deductible amount.
GARAGE KEEPERS LOC # Five Enter number: The producer assigned number for the location. The location number for the garage keepers coverages should correspond to a location number documented on the ACORD 125.

ACORD 138 LA (2009/01) rev. 03-27-2009 8 of 11

Section Name Field Name Field and/or Section Description
Enter the Limits for Each Location
GARAGE KEEPERS Five Enter limit: The garage keepers collision limit amount.
GARAGE KEEPERS # of Autos Five Enter number: The number of vehicles located on the premises.
GARAGE KEEPERS Deductible Per Auto Five Enter deductible: The garage keepers collision per auto deductible amount.
GARAGE KEEPERS LOC # Six Enter number: The producer assigned number for the location. The location number for the garage keepers coverages should correspond to a location number documented on the ACORD 125.
Enter the Limits for Each Location
GARAGE KEEPERS Six Enter limit: The garage keepers collision limit amount.
GARAGE KEEPERS # of Autos Six Enter number: The number of vehicles located on the premises.
GARAGE KEEPERS Deductible Per Auto Six Enter deductible: The garage keepers collision per auto deductible amount.
GARAGE KEEPERS 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).
Additional Coverage Covered Auto
GARAGE KEEPERS Symbols Enter text: The symbols that apply to the other coverage listed.
GARAGE KEEPERS Additional Coverage Limit Enter limit: The limit amount of the other coverage.
Enter text: The timing of the reporting period if the policy will be on a Reporting basis.
GARAGE KEEPERS Physical Damage Reporting Period Examples: Monthly, Quarterly, Semi-Annual.
GARAGE KEEPERS Physical Damage Non-Reporting Check the box (if applicable): Indicates the policy is on a non-reporting basis.
Enter number: The total number of sets of dealer or repairer plates issued to the named
GARAGE KEEPERS # Dealer Plates/Repairer Plates insured.
GARAGE KEEPERS # Transportation Plates Enter number: The total number of sets of transportation plates issued to the applicant.
GARAGE KEEPERS # Hoists Enter number: The total number of hoists located on the premises.
GARAGE KEEPERS Temporary Location Limit Enter limit: The limit for covered autos stored temporarily off premises.
GARAGE KEEPERS Transit Limit Enter limit: The limit for covered autos in transit.
Enter text: The remarks associated with the Garage and Dealers line of business. Enter
any endorsements that apply. Be sure to include the form numbers and the required
ENDORSEMENTS / information for attaching the endorsement. Attach ACORD 101, Additional Remarks
REMARKS Endorsements / Remarks Schedule, if more space is required.
Sign here: Accommodates the signature of the applicant or named insured. As used here,
the applicant should read and understand the Fair Credit Reporting Act, the Privacy Act
(where applicable), the Applicant's Statement, and any other disclosure information on the
SIGNATURE Applicant's Signature form before personally signing the application.

ACORD 138 LA (2009/01) rev. 03-27-2009 9 of 11

Section Name Field Name Field and/or Section Description
SIGNATURE Date Enter date: The date the form was signed by the named insured.
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
SIGNATURE Producer's Signature agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
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
SIGNATURE National Producer Number state license number.
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE I select UMBI Coverage which provides compensation for economic and non-economic losses with limits lower than the Bodily Injury Liability Coverage limits indicated on the policy: Initial here: The named insured's initials. As used here, indicates the named insured has selected uninsured motorists bodily injury coverage including economic and non-economic losses with lower limits than the bodily injury coverage.
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE UMBI Coverage Each Person Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.)
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE UMBI Coverage Each Accident / Occurrence Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
UNINSURED /
UNDERINSURED
MOTORIST BODILY INJURY UMBI Coverage Each Accident /
COVERAGE Occurrence Enter limit: The uninsured motorists combined single limit per accident limit amount.
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE I select Economic-Only UMBI Coverage, which provides compensation for economic losses with the same limits as the Bodily Injury Liability Coverage indicated on the policy. Initial here: The named insured's initials. As used here, indicates the named insured has selected uninsured motorists bodily injury coverage including economic losses only with the same limits as the bodily injury coverage.

ACORD 138 LA (2009/01) rev. 03-27-2009 10 of 11

Section Name Field Name Field and/or Section Description
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE I select Economic-Only UMBI Coverage, which provides compensation for economic losses with limits lower than the Bodily Injury Liability Coverage limits indicated on the policy: Initial here: The named insured's initials. As used here, indicates the named insured has selected uninsured motorists bodily injury coverage including economic losses only with lower limits than the bodily injury coverage.
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE UMBI Coverage Each Person Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.)
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE UMBI Coverage Each Accident / Occurrence Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
UNINSURED /
UNDERINSURED
MOTORIST BODILY INJURY UMBI Coverage Each Accident /
COVERAGE Occurrence Enter limit: The uninsured motorists combined single limit per accident limit amount.
UNINSURED /
UNDERINSURED
MOTORIST BODILY INJURY Initial here: The named insured's initials. As used here, indicates the named insured has
COVERAGE I Do Not Want UMBI Coverage rejected uninsured motorists bodily injury coverage.
UNINSURED /
UNDERINSURED
MOTORIST BODILY INJURY Signature of Named Insured or
COVERAGE Legal Representative Sign here: Accommodates the signature of the applicant or named insured.
UNINSURED /
UNDERINSURED
MOTORIST BODILY INJURY
COVERAGE Print Name Enter text: The named insured(s) as it/they will appear on the policy declarations page.
UNINSURED /
UNDERINSURED
MOTORIST BODILY INJURY
COVERAGE Date Enter date: The date the form was signed by the named insured.
Section Name Field Name Field and/or Section Description
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE Optional Information for Policy Indentification Only Enter text: The remarks associated with the Garage and Dealers line of business. Enter any endorsements that apply. Be sure to include the form numbers and the required information for attaching the endorsement. Attach ACORD 101, Additional Remarks Schedule, if more space is required. As used here, contains optional information for policy identification purposes only.
UNINSURED / UNDERINSURED MOTORIST BODILY INJURY COVERAGE Individual Company Name, Group Name and/or logo 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.
The edition identifier of the form including the form number and edition (the date is
Edition Date typically formatted YYYY/MM).

ACORD 138 LA (2009/01) rev. 03-27-2009 11 of 11