ACORD 137 WA (2014/12) - WASHINGTON COMMERCIAL AUTO COVERAGES / LIMITS SECTION

ACORD 137 WA (2014/12) - WASHINGTON COMMERCIAL AUTO COVERAGES / LIMITS SECTION
ACORD 137 WA, Washington 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 coverage is revised to reflect Washington's unique coverages and options. Refer to your state Manual.
* Added Auto Loan coverage in the Coverages / Premium section.
* State Specific Fraud Warning
* Statement added to the form referring to the options available under Underinsured Motorists and the applicant's right to reject these coverages.
Applicant must initial the selected option(s).
* Mandatory Offer of Personal Injury Protection Coverage is on Page 4 of the application.
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
Name 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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 1 of 27
BUSINESS AUTO SECTION
Liability - 1
Check the box (if applicable): Indicates that any auto is covered.
BUSINESS AUTO SECTION
2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION
4
Check the box (if applicable): Indicates that owned autos other than private passenger autos are
covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION
9
Check the box (if applicable): Indicates that non-owned autos are covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
BUSINESS AUTO SECTION
BI Ea Person
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on
the coverage.
BUSINESS AUTO 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).
BUSINESS AUTO 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).
BUSINESS AUTO 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).
BUSINESS AUTO SECTION
Personal Injury Protection -
2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Medical Expense
Enter limit: The personal injury protection (PIP) medical expense limit amount.
BUSINESS AUTO SECTION
Service Loss
Enter limit: The limit amount for the other expense - service loss benefit coverage.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 2 of 27
BUSINESS AUTO SECTION
Income Contin
Enter limit: The personal injury protection (PIP) income continuation limit amount.
BUSINESS AUTO SECTION
Funeral Expense
Enter limit: The limit amount for the other expense - funeral expense coverage.
BUSINESS AUTO SECTION
Additional P.I.P - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Limit
Enter limit: The additional personal injury protection (APIP) limit amount.
BUSINESS AUTO SECTION
Medical Payments - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION
4
Check the box (if applicable): Indicates that owned autos other than private passenger autos are
covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Each Person
Enter limit: The medical payments per person limit.
BUSINESS AUTO SECTION
Underinsured Motorists - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION
4
Check the box (if applicable): Indicates that owned autos other than private passenger autos are
covered.
BUSINESS AUTO SECTION
6
Check the box (if applicable): Indicates that owned autos subject to compulsory uninsured
motorists law are covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 WA (2014/12) rev. 02-27-2014
Page 3 of 27
BUSINESS AUTO SECTION
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
BUSINESS AUTO SECTION
BI Ea Person
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on
the coverage.
BUSINESS AUTO SECTION
Limit
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.
BUSINESS AUTO SECTION
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.
BUSINESS AUTO SECTION
Property Damage
Enter limit: The underinsured motorists property damage per accident amount. The use of this
limit varies by state.
BUSINESS AUTO SECTION
Deductible
Enter deductible: The underinsured motorists property damage deductible amount. The use of
this limit varies by state.
BUSINESS AUTO SECTION
Hired / Borrowed Liability -
Yes
Check the box (if applicable): Indicates if hired / borrowed coverage applies.
BUSINESS AUTO SECTION
States
Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO SECTION
No
Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
BUSINESS AUTO SECTION
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
BUSINESS AUTO 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.
BUSINESS AUTO SECTION
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 SECTION
States
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 4 of 27
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO SECTION
No
Check the box (if applicable): Indicates that non-owned coverage does not apply.
BUSINESS AUTO SECTION
Group Type - Employees
Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees.
BUSINESS AUTO SECTION
Number Of Employees
Enter number: The number of employees that use their own automobiles.
BUSINESS AUTO SECTION
Volunteers
Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers.
BUSINESS AUTO SECTION
Number Of Volunteers
Enter number: The number of volunteers that use their own automobiles.
BUSINESS AUTO SECTION
Partners
Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners.
BUSINESS AUTO SECTION
Number Of Partners
Enter number: The number of partners that use their own automobiles.
BUSINESS AUTO 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).
BUSINESS AUTO SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
BUSINESS AUTO 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).
BUSINESS AUTO SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
BUSINESS AUTO SECTION
Towing & Labor - 3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Limit
Enter limit: The towing and labor limit amount.
BUSINESS AUTO SECTION
COMP / OTC - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 5 of 27
BUSINESS AUTO SECTION
4
Check the box (if applicable): Indicates that owned autos other than private passenger autos are
covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Specified Causes of Loss - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION
4
Check the box (if applicable): Indicates that owned autos other than private passenger autos are
covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Collision - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO SECTION
4
Check the box (if applicable): Indicates that owned autos other than private passenger autos are
covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Auto Loan - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO SECTION
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 6 of 27
BUSINESS AUTO SECTION
4
Check the box (if applicable): Indicates that owned autos other than private passenger autos are
covered.
BUSINESS AUTO SECTION
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO SECTION
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
BUSINESS AUTO SECTION
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 SECTION
Limit
Enter limit: The auto loan coverage limit amount.
BUSINESS AUTO 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).
BUSINESS AUTO SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
BUSINESS AUTO SECTION
Hired Physical Damage -
States
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO SECTION
# Days
Enter number: The number of days needed to rate Hired Physical Damage Coverage.
BUSINESS AUTO SECTION
# Veh
Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
BUSINESS AUTO SECTION
Coverage / Deductible -
Comp
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
BUSINESS AUTO SECTION
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
ACORD 137 WA (2014/12) rev. 02-27-2014
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BUSINESS AUTO SECTION
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 SECTION
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 SECTION
Coll
Check the box (if applicable): Indicates the vehicle has collision coverage.
BUSINESS AUTO SECTION
Deductible
Enter deductible: The collision deductible amount.
BUSINESS AUTO SECTION
Coverage is: - Primary
Check the box (if applicable): Indicates if this coverage is on a primary basis.
BUSINESS AUTO SECTION
Secondary
Check the box (if applicable): Indicates if this coverage is on a secondary basis.
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
1. I have selected UIM limits
equal to my BI and PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits equal to their Bodily Injury and Property Damage
Coverage.
SIGNATURE
2. I have selected UIM limits
equal to my BI Coverage,
but UIM PD limits lower than
my PD Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits equal to their Bodily Injury Coverage, but Underinsured
Motorists Property Damage limits lower than their Property Damage Coverage.
SIGNATURE
3. I have selected UIM limits
lower than my BI Coverage,
but UIM PD limits equal to
my PD coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits lower than their Bodily Injury Coverage, but Underinsured
Motorists Property Damage limits equal to their Property Damage coverage.
SIGNATURE
4. I have selected UIM BI
limits and UIM PD limits
lower than my BI and PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists Bodily Injury limits and Underinsured Motorists Property
Damage limits lower than their Bodily Injury and Property Damage Coverage.
SIGNATURE
5. I have rejected UIM BI
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected Underinsured Motorists Bodily Injury Coverage.
ACORD 137 WA (2014/12) rev. 02-27-2014
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SIGNATURE
6. I have rejected UIM PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected 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 SECTION
Liability - 41
Check the box (if applicable): Indicates that any auto is covered.
TRUCKERS SECTION
42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION
50
Check the box (if applicable): Indicates that non-owned autos only are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
TRUCKERS SECTION
BI Ea Person
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on
the coverage.
TRUCKERS 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).
TRUCKERS 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).
ACORD 137 WA (2014/12) rev. 02-27-2014
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TRUCKERS 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).
TRUCKERS SECTION
Personal Injury Protection -
44
Check the box (if applicable): Indicates that owned autos subject to no-fault are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
Medical Expense
Enter limit: The personal injury protection (PIP) medical expense limit amount.
TRUCKERS SECTION
Service Loss
Enter limit: The limit amount for the other expense - service loss benefit coverage.
TRUCKERS SECTION
Income Contin
Enter limit: The personal injury protection (PIP) income continuation limit amount.
TRUCKERS SECTION
Funeral Expense
Enter limit: The limit amount for the other expense - funeral expense coverage.
TRUCKERS SECTION
Additional P.I.P - 44
Check the box (if applicable): Indicates that owned autos subject to no-fault are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
Limit
Enter limit: The additional personal injury protection (APIP) limit amount.
TRUCKERS SECTION
Medical Payments - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
Each Person
Enter limit: The medical payments per person limit.
TRUCKERS SECTION
Underinsured Motorists - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION
45
Check the box (if applicable): Indicates that owned autos subject to a compulsory uninsured
motorist law are covered.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 10 of 27
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
TRUCKERS SECTION
BI Ea Person
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on
the coverage.
TRUCKERS SECTION
Limit
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.
TRUCKERS SECTION
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.
TRUCKERS SECTION
Property Damage
Enter limit: The underinsured motorists property damage per accident amount. The use of this
limit varies by state.
TRUCKERS SECTION
Deductible
Enter deductible: The underinsured motorists property damage deductible amount. The use of
this limit varies by state.
TRUCKERS SECTION
Non-Truckers Hired /
Borrowed Liability - Yes
Check the box (if applicable): Indicates if hired / borrowed coverage applies.
TRUCKERS SECTION
States
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION
No
Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
TRUCKERS SECTION
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
TRUCKERS 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.
TRUCKERS SECTION
Truckers Hired / Borrowed
Liability - Yes
Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies.
TRUCKERS SECTION
States
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired or borrowed.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 11 of 27
TRUCKERS SECTION
No
Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not apply.
TRUCKERS SECTION
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
TRUCKERS 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.
TRUCKERS SECTION
Non-Owned Auto Liability -
Yes
Check the box (if applicable): Indicates if non-owned coverage applies.
TRUCKERS SECTION
States
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
Enter code: Indicates a state where autos are non-owned.
TRUCKERS SECTION
No
Check the box (if applicable): Indicates that non-owned coverage does not apply.
TRUCKERS SECTION
Group Type - Employees
Check the box (if applicable): Indicates that non-owned liability coverage pertains to employees.
TRUCKERS SECTION
Number Of Employees
Enter number: The number of employees that use their own automobiles.
TRUCKERS SECTION
Volunteers
Check the box (if applicable): Indicates that non-owned liability coverage pertains to volunteers.
TRUCKERS SECTION
Number Of Volunteers
Enter number: The number of volunteers that use their own automobiles.
TRUCKERS SECTION
Partners
Check the box (if applicable): Indicates that non-owned liability coverage pertains to partners.
TRUCKERS SECTION
Number Of Partners
Enter number: The number of partners that use their own automobiles.
TRUCKERS 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).
TRUCKERS SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
TRUCKERS SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 12 of 27
TRUCKERS 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).
TRUCKERS SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
TRUCKERS SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
TRUCKERS 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).
TRUCKERS SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
TRUCKERS SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
TRUCKERS SECTION
COMP / OTC - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
TRUCKERS SECTION
Specified Causes of Loss -
42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
SCL
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
TRUCKERS SECTION
F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 13 of 27
TRUCKERS SECTION
FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
TRUCKERS SECTION
FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on
this vehicle.
TRUCKERS SECTION
LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on
this vehicle.
TRUCKERS SECTION
Deductible
Enter deductible: The deductible associated with specified causes of loss coverage.
TRUCKERS SECTION
Collision - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
Deductible
Enter deductible: The collision deductible amount.
TRUCKERS SECTION
Towing & Labor - 46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
Limit
Enter limit: The towing and labor limit amount.
TRUCKERS SECTION
Auto Loan - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS SECTION
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS SECTION
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS SECTION
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS SECTION
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
TRUCKERS SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS SECTION
Limit
Enter limit: The auto loan coverage limit amount.
TRUCKERS SECTION
COMP / OTC - 48
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 14 of 27
TRUCKERS SECTION
49
Check the box (if applicable): Indicates that your trailers in the possession of another trucker
under a trailer interchange agreement are covered.
TRUCKERS SECTION
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
TRUCKERS SECTION
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS 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.
TRUCKERS SECTION
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy, are
pulled by other tractors.
TRUCKERS SECTION
Specified Causes of Loss -
48
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
TRUCKERS SECTION
49
Check the box (if applicable): Indicates that your trailers in the possession of another trucker
under a trailer interchange agreement are covered.
TRUCKERS SECTION
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
TRUCKERS SECTION
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS 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.
TRUCKERS SECTION
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy, are
pulled by other tractors.
TRUCKERS SECTION
Collision - 48
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
TRUCKERS SECTION
49
Check the box (if applicable): Indicates that your trailers in the possession of another trucker
under a trailer interchange agreement are covered.
TRUCKERS SECTION
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
TRUCKERS SECTION
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS 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.
TRUCKERS SECTION
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy, are
pulled by other tractors.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 15 of 27
TRUCKERS SECTION
Deductible
Enter deductible: The deductible amount applicable to trailer interchange collision coverage.
TRUCKERS SECTION
Trailer Value
Enter amount: The trailer value as assigned by the trailer interchange agreement.
TRUCKERS SECTION
Hired Physical Damage -
States
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS SECTION
# Days
Enter number: The number of days needed to rate Hired Physical Damage Coverage.
TRUCKERS SECTION
# Veh
Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
TRUCKERS SECTION
Coverage is: - Primary
Check the box (if applicable): Indicates if this coverage is on a primary basis.
TRUCKERS SECTION
Secondary
Check the box (if applicable): Indicates if this coverage is on a secondary basis.
TRUCKERS 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).
TRUCKERS SECTION
Additional Coverage
Covered Auto Symbols
Enter text: The symbols that apply to the other coverage listed.
TRUCKERS 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
1. I have selected UIM limits
equal to my BI and PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits equal to their Bodily Injury and Property Damage
Coverage.
SIGNATURE
2. I have selected UIM limits
equal to my BI Coverage,
but UIM PD limits lower than
my PD Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits equal to their Bodily Injury Coverage, but Underinsured
Motorists Property Damage limits lower than their Property Damage Coverage.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 16 of 27
SIGNATURE
3. I have selected UIM limits
lower than my BI Coverage,
but UIM PD limits equal to
my PD coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits lower than their Bodily Injury Coverage, but Underinsured
Motorists Property Damage limits equal to their Property Damage coverage.
SIGNATURE
4. I have selected UIM BI
limits and UIM PD limits
lower than my BI and PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists Bodily Injury limits and Underinsured Motorists Property
Damage limits lower than their Bodily Injury and Property Damage Coverage.
SIGNATURE
5. I have rejected UIM BI
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected Underinsured Motorists Bodily Injury Coverage.
SIGNATURE
6. I have rejected UIM PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected 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.
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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 17 of 27
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 Person
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
Personal Injury Protection -
65
Check the box (if applicable): Indicates that owned autos subject to no-fault 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
Medical Expense
Enter limit: The personal injury protection (PIP) medical expense limit amount.
MOTOR CARRIER SECTION
Service Loss
Enter limit: The limit amount for the other expense - service loss benefit coverage.
MOTOR CARRIER SECTION
Income Contin
Enter limit: The personal injury protection (PIP) income continuation limit amount.
MOTOR CARRIER SECTION
Funeral Expense
Enter limit: The limit amount for the other expense - funeral expense coverage.
MOTOR CARRIER SECTION
Additional P.I.P - 65
Check the box (if applicable): Indicates that owned autos subject to no-fault 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 additional personal injury protection (APIP) limit amount.
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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 18 of 27
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
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.
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 Person
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 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.
MOTOR CARRIER SECTION
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.
MOTOR CARRIER SECTION
Property Damage
Enter limit: The underinsured motorists property damage per accident amount. The use of this
limit varies by state.
MOTOR CARRIER SECTION
Deductible
Enter deductible: The underinsured motorists property damage deductible amount. The use of
this limit varies by state.
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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 19 of 27
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.
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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 20 of 27
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.
MOTOR CARRIER SECTION
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
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.
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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 21 of 27
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.
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
Auto Loan - 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 WA (2014/12) rev. 02-27-2014
Page 22 of 27
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
Limit
Enter limit: The auto loan coverage 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.
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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 23 of 27
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
Trailer Value
Enter amount: The trailer value as assigned by the trailer interchange agreement.
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.
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.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 24 of 27
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
1. I have selected UIM limits
equal to my BI and PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits equal to their Bodily Injury and Property Damage
Coverage.
SIGNATURE
2. I have selected UIM limits
equal to my BI Coverage,
but UIM PD limits lower than
my PD Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits equal to their Bodily Injury Coverage, but Underinsured
Motorists Property Damage limits lower than their Property Damage Coverage.
SIGNATURE
3. I have selected UIM limits
lower than my BI Coverage,
but UIM PD limits equal to
my PD coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists limits lower than their Bodily Injury Coverage, but Underinsured
Motorists Property Damage limits equal to their Property Damage coverage.
SIGNATURE
4. I have selected UIM BI
limits and UIM PD limits
lower than my BI and PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists Bodily Injury limits and Underinsured Motorists Property
Damage limits lower than their Bodily Injury and Property Damage Coverage.
SIGNATURE
5. I have rejected UIM BI
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected Underinsured Motorists Bodily Injury Coverage.
SIGNATURE
6. I have rejected UIM PD
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected 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 4
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).
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 25 of 27
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Health and Hospital Benefits
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Health and Hospital Benefits of $10,000 per each insured.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Funeral Benefits
Initial here: The named insured's initials. As used here, indicates the named insured has
selected funeral benefits of $2,000 per each insured for funeral expenses.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Income Continuation
Initial here: The named insured's initials. As used here, indicates the named insured has
selected up to $10,000 per each insured to cover income losses incurred within one year after
the date of the insured's injury.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Loss of Services Benefit.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit $
amount per each insured
Enter limit: The per insured person limit amount for the other expense - service loss benefit
coverage.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit $
amount per day
Enter limit: The per day limit amount for the other expense - service loss benefit coverage.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit not
to exceed $ amount per
week
Enter limit: The per week limit amount for the other expense - service loss benefit coverage.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Health and Hospital Benefits
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Health and Hospital Benefits of $35,000 per each insured.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Income Continuation
Initial here: The named insured's initials. As used here, indicates the named insured has
selected up to $35,000 per each insured to cover income losses incurred within one year after
the date of the insured's injury.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Loss of Services Benefit.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit $
amount per each insured
Enter limit: The per insured person limit amount for the other expense - service loss benefit
coverage.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit $
amount per day
Enter limit: The per day limit amount for the other expense - service loss benefit coverage.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 26 of 27
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Loss of Services Benefit not
to exceed $ amount per
week
Enter limit: The per week limit amount for the other expense - service loss benefit coverage.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
I reject Personal Injury
Protection in its entirety
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected Personal Injury Protection Coverage in its entirety.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
MANDATORY OFFER OF
PERSONAL INJURY
PROTECTION COVERAGE
Date
Enter date: The date the form was signed by the named insured.
ACORD 137 WA (2014/12) rev. 02-27-2014
Page 27 of 27