ACORD 138 MA (2012/02)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 138 MA (2012/02)
Massachusetts Garage and
Dealers Coverages / Limits
Section
ACORD 138 MA, Massachusetts 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.
* All coverages have been revised to reflect Massachusetts' unique requirements. Refer
to your state manual.
* The Fair Credit Reporting Act and fraud statements are revised to comply with
Massachusetts law and regulation.
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.
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.
COVERAGES / LIMITS
Garage Auto Only (checkbox)
Check the box (if applicable): Indicates the policy coverage includes automobile. Note
that automobile and premises operations coverages can apply.
COVERAGES / LIMITS
Garage Auto and Premises
Operations (checkbox)
Check the box (if applicable): Indicates the policy coverage is for automobile and
premises operations.
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Section Name
Field Name
Field and/or Section Description
COVERAGES / LIMITS
Bodily Injury Liability 21
(checkbox)
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
Bodily Injury Liability 22
(checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Bodily Injury Liability 23
(checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Bodily Injury Liability 24
(checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
COVERAGES / LIMITS
Bodily Injury Liability 27
(checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Bodily Injury Liability 28
(checkbox)
Check the box (if applicable): Indicates only hired autos are covered.
COVERAGES / LIMITS
Bodily Injury Liability 29
(checkbox)
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 ($)
Enter limit: The liability aggregate limit for garage operations other than auto only.
COVERAGES / LIMITS
Dealers Only-Limited (checkbox)
Check the box (if applicable): Indicates the liability coverage is limited for dealers.
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Section Name
Field Name
Field and/or Section Description
COVERAGES / LIMITS
Dealers Only-Unlimited (checkbox)
Check the box (if applicable): Indicates the liability coverage is unlimited for dealers.
COVERAGES / LIMITS
Compulsory Personal Injury
Protection 25 (checkbox)
Check the box (if applicable): Indicates owned autos subject to no-fault are covered.
COVERAGES / LIMITS
Compulsory Personal Injury
Protection 27 (checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
COVERAGES / LIMITS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
COVERAGES / LIMITS
Compulsory Personal Injury
Protection Per Person Field ($)
Enter limit: The personal injury protection (PIP) per person limit amount.
COVERAGES / LIMITS
Compulsory Personal Injury
Protection Ded Field ($)
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
COVERAGES / LIMITS
Compulsory Personal Injury
Protection-Yourself (checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured.
COVERAGES / LIMITS
Yourself and Family Members
(checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured and family members.
COVERAGES / LIMITS
Compulsory: Damage To Someone
Else's Property 21 (checkbox)
Check the box (if applicable): Indicates any auto is covered.
COVERAGES / LIMITS
Compulsory: Damage To Someone
Else's Property 22 (checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Compulsory: Damage To Someone
Else's Property 23 (checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Compulsory: Damage To Someone
Else's Property 24 (checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
COVERAGES / LIMITS
Compulsory: Damage To Someone
Else's Property 27 (checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Compulsory: Damage To Someone
Else's Property 28 (checkbox)
Check the box (if applicable): Indicates only hired autos are covered.
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Section Name
Field Name
Field and/or Section Description
COVERAGES / LIMITS
Compulsory: Damage To Someone
Else's Property 29 (checkbox)
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
Compulsory: Damage to Someone
Else's Property-Each Accident
Field ($)
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).
COVERAGES / LIMITS
Optional Medical Payments 21
(checkbox)
Check the box (if applicable): Indicates any auto is covered.
COVERAGES / LIMITS
Optional Medical Payments 22
(checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Optional Medical Payments 23
(checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Optional Medical Payments 24
(checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
COVERAGES / LIMITS
Optional Medical Payments 27
(checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Optional Medical Payments 28
(checkbox)
Check the box (if applicable): Indicates only hired autos are covered.
COVERAGES / LIMITS
Optional Medical Payments 29
(checkbox)
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
Optional Medical Payments-Each
Person Field ($)
Enter limit: The medical payments per person limit.
COVERAGES / LIMITS
Compulsory Uninsured Motorist
22 (checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Compulsory Uninsured Motorist
23 (checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Compulsory Uninsured Motorist
24 (checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
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Section Name
Field Name
Field and/or Section Description
COVERAGES / LIMITS
Compulsory Uninsured Motorist
26 (checkbox)
Check the box (if applicable): Indicates owned autos subject to uninsured motorists law
are covered.
COVERAGES / LIMITS
Compulsory Uninsured Motorist
27 (checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
COVERAGES / LIMITS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
COVERAGES / LIMITS
Compulsory Uninsured Motorists-
CSL (checkbox)
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
COVERAGES / LIMITS
BI Ea Per (checkbox)
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
COVERAGES / LIMITS
BI Ea Per ($)
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
Underinsured Motorist 22
(checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Underinsured Motorist 23
(checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Underinsured Motorist 24
(checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
COVERAGES / LIMITS
Underinsured Motorist 26
(checkbox)
Check the box (if applicable): Indicates owned autos subject to uninsured motorists law
are covered.
COVERAGES / LIMITS
Underinsured Motorist 27
(checkbox)
Check the box (if applicable): Indicates specifically described autos 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
Underinsured Motorists-CSL
(Checkbox)
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
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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
BI Ea Per ($)
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
COVERAGES / LIMITS
BI Each Accident ($)
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
COVERAGES / LIMITS
Optional Bodily Injury To Others
21 (checkbox)
Check the box (if applicable): Indicates any auto is covered.
COVERAGES / LIMITS
Optional Bodily Injury To Others
22 (checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Optional Bodily Injury To Others
23 (checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Optional Bodily Injury To Others
24 (checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
COVERAGES / LIMITS
Optional Bodily Injury To Others
27 (checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Optional Bodily Injury To Others
28 (checkbox)
Check the box (if applicable): Indicates only hired autos are covered.
COVERAGES / LIMITS
Optional Bodily Injury To Others
29 (checkbox)
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
Optional Bodily Injury To Others
Each Person Field ($)
Enter limit: The optional bodily injury to others per person limit amount.
COVERAGES / LIMITS
Optional Bodily Injury To Others-
Each Accident Field ($)
Enter limit: The optional bodily injury to others per accident limit amount.
PHYSICAL DAMAGE
Comp / OTC (checkbox)
Check the box (if applicable): Indicates the physical damage is comprehensive/other than
collision.
PHYSICAL DAMAGE
Specified Perils (checkbox)
Check the box (if applicable): Indicates the physical damage coverage is for specified
perils.
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Section Name
Field Name
Field and/or Section Description
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 (checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
PHYSICAL DAMAGE
Specified Perils 23 (checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
PHYSICAL DAMAGE
Specified Perils 24 (checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
PHYSICAL DAMAGE
Specified Perils 27 (checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
PHYSICAL DAMAGE
Specified Perils 28 (checkbox)
Check the box (if applicable): Indicates only hired autos are covered.
PHYSICAL DAMAGE
Specified Perils 31 (checkbox)
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
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.
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Section Name
Field Name
Field and/or Section Description
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
Optional Collision 22 (checkbox)
Check the box (if applicable): Indicates all owned autos are covered.
PHYSICAL DAMAGE
Optional Collision 23 (checkbox)
Check the box (if applicable): Indicates only owned private passengers autos are covered.
PHYSICAL DAMAGE
Optional Collision 24 (checkbox)
Check the box (if applicable): Indicates owned autos other than private passenger autos
are covered.
PHYSICAL DAMAGE
Optional Collision 27 (checkbox)
Check the box (if applicable): Indicates specifically described autos are covered.
PHYSICAL DAMAGE
Optional Collision 28 (checkbox)
Check the box (if applicable): Indicates only hired autos are covered.
PHYSICAL DAMAGE
Optional Collision 31 (checkbox)
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
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 collision limit amount.
PHYSICAL DAMAGE
Collision-Deductible ($)
Enter deductible: The physical damage collision per auto deductible 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 collision limit amount.
PHYSICAL DAMAGE
Collision-Deductible
Enter deductible: The physical damage collision per auto deductible 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 collision limit amount.
PHYSICAL DAMAGE
Collision-Deductible
Enter deductible: The physical damage collision per auto deductible amount.
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.
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Section Name
Field Name
Field and/or Section Description
GARAGE KEEPERS
Garage Keepers Legal Liability
(checkbox)
Check the box (if applicable): Indicates the policy is to be written on a legal liability basis.
GARAGE KEEPERS
Direct Basis (checkbox)
Check the box (if applicable): Indicates the policy is to be written on a direct basis.
GARAGE KEEPERS
Primary (checkbox)
Check the box (if applicable): Indicates this policy is the primary coverage.
GARAGE KEEPERS
Excess (checkbox)
Check the box (if applicable): Indicates this policy is for excess coverage.
GARAGE KEEPERS
Comp / OTC (checkbox)
Check the box (if applicable): Indicates the garage keepers coverage is
comprehensive/other than collision.
GARAGE KEEPERS
Specified Perils (checkbox)
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.
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.
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Section Name
Field Name
Field and/or Section Description
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.
GARAGE KEEPERS
Enter the Limits for Each Location
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.
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Section Name
Field Name
Field and/or Section Description
GARAGE KEEPERS
Enter the Limits for Each Location
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).
GARAGE KEEPERS
Additional Coverage Covered Auto
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.
GARAGE KEEPERS
Physical Damage Reporting Period
Enter text: The timing of the reporting period if the policy will be on a Reporting basis.
Examples: Monthly, Quarterly, Semi-Annual.
GARAGE KEEPERS
Physical Damage Non Reporting
Period (checkbox)
Check the box (if applicable): Indicates the policy is on a non-reporting basis.
GARAGE KEEPERS
# Dealer Plates/Repairer Plates
Enter number: The total number of sets of dealer or repairer plates issued to the named
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.
ENDORSEMENTS /
REMARKS
Endorsements / Remarks
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. ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
SIGNATURE
Applicant's Signature
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
form before personally signing the application.
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.) by all companies to issue Certificates. 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.
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Section Name
Field Name
Field and/or Section Description
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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