ACORD 138 KY (2014/12) - KENTUCKY GARAGE AND DEALERS COVERAGES / LIMITS SECTION
ACORD 138 KY (2014/12) - KENTUCKY GARAGE AND DEALERS COVERAGES / LIMITS SECTION
ACORD 138 KY, Kentucky 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:
* Provision is made to report the Tax Territory, as required by Kentucky law.
* Personal Injury Protection coverages are revised to reflect Kentucky's unique coverages and options. Refer to you state manual.
* Provision is made to select stacked or non-stacked Uninsured and Underinsured Motorists Bodily Injury coverage.
* Uninsured and Underinsured Motorists Property Damage coverage are not available.
* A state-specific fraud warning is included.
* Statement added acknowledging the explanation to the applicant of Uninsured (UM) and Underinsured (UIM) Motorists coverages and available
options; applicant may reject UM and/or UIM by initialing the rejected coverage.
* Section added to capture descriptions of motorcycles, and named individuals to be covered, as required under PIP options.
* If garaging location is not within city limits, the name(s) of applicable tax territories must be provided.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
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. (MM/DD/YYYY)
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. (MM/DD/YYYY)
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
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IDENTIFICATION SECTION
Tax Territory
Enter code: The city, county or state tax code.
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
Automobile checkbox
Check the box (if applicable): Indicates the policy coverage includes automobile. Note that both
automobile and premises operations coverages can apply.
COVERAGES / LIMITS
Premises Operations
checkbox
Check the box (if applicable): Indicates the policy coverage includes premises operations. Note
that both automobile and premises operations coverages can apply.
COVERAGES / LIMITS
Liability 21
Check the box (if applicable): Indicates any auto is covered. As used here, Garage or Dealers
policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for
which coverage is in effect. Be sure to check the appropriate box for each type of coverage.
Only those symbols specified for a coverage may be used. Symbols 21 through 26 provide fleet
automatic coverage. Symbol 21 includes Hired and Non-Owned auto coverage. If symbol 21 is
not used and Hired Auto (symbol 28) or Non-Owned Auto (symbol 29) coverage is desired,
those symbols must be checked.
The symbols indicate the automobiles to which each coverage applies. The symbol triggers
the coverage. For exact policy definitions of the symbols, please refer to the company's policy
declarations page.
COVERAGES / LIMITS
Liability 22
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Liability 23
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Liability 24
Check the box (if applicable): Indicates owned autos other than private passenger autos are
covered.
COVERAGES / LIMITS
Liability 27
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Liability 28
Check the box (if applicable): Indicates only hired autos are covered.
COVERAGES / LIMITS
Liability 29
Check the box (if applicable): Indicates non-owned autos used in garage business are covered.
COVERAGES / LIMITS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or
enter a company-unique symbol if applicable.
COVERAGES / LIMITS
Ea Acc ($) Auto Only
Enter limit: The liability each accident limit for garage operations auto only. For Dealers, use
this field to enter the Policy Combined Single Limit.
COVERAGES / LIMITS
Ea Acc ($) Other than Auto
Only
Enter limit: The liability each accident limit for garage operations other than auto only.
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COVERAGES / LIMITS
Aggregate ($)
Enter limit: The liability aggregate limit for garage operations other than auto only.
COVERAGES / LIMITS
Dealers Only-Limited
Check the box (if applicable): Indicates the liability coverage is limited for dealers.
COVERAGES / LIMITS
Dealers Only-Unlimited
Check the box (if applicable): Indicates the liability coverage is unlimited for dealers.
COVERAGES / LIMITS
Personal Injury Protection
25
Check the box (if applicable): Indicates owned autos subject to no-fault are covered.
COVERAGES / LIMITS
Personal Injury Protection
27
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or
enter a company-unique symbol if applicable.
COVERAGES / LIMITS
Personal Injury
Protection-Amount Field ($)
Enter limit: The personal injury protection (PIP) limit amount. As used here, refer to applicable
State Manual for Options. Include any deductible selected by the applicant.
COVERAGES / LIMITS
DED Field
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
COVERAGES / LIMITS
Full (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) full option has been
selected and all parties accept the personal injury protection (PIP) limitations.
COVERAGES / LIMITS
Guest Only (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) tort limitations has
been selected for guests only. There is no coverage for insureds.
COVERAGES / LIMITS
Buy Back (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) limitations have been
accepted by one or more insureds.
COVERAGES / LIMITS
Additional P.I.P 25
Check the box (if applicable): Indicates owned autos subject to no-fault are covered.
COVERAGES / LIMITS
Additional P.I.P 27
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
Additional P.I.P-Option #
Enter number: The additional personal injury protection (APIP) option number used by the
company as it relates to the limit. This may be provided in lieu of the limit, or it may be sent in
addition to the limit.
COVERAGES / LIMITS
Aggregate Limit
Enter limit: The additional personal injury protection (APIP) limit amount.
COVERAGES / LIMITS
Motorcycle P.I.P 25
Check the box (if applicable): Indicates owned autos subject to no-fault are covered.
COVERAGES / LIMITS
Motorcycle P.I.P 27
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.
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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
Motorcycle P.I.P. - Applies
to Cycles Listed on Page 2
(Checkbox)
Check the box (if applicable): Indicates the motorcycles covered are listed on the last page of
the form.
COVERAGES / LIMITS
Amount
Enter limit: The motorcycle personal injury protection (MPIP) limit amount.
COVERAGES / LIMITS
Named Individual
Broadened P.I.P 25
Check the box (if applicable): Indicates owned autos subject to no-fault are covered.
COVERAGES / LIMITS
Named Individual
Broadened P.I.P 27
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
Named Individual
Broadened P.I.P. - Applies to
Individuals Listed on Page 2
(Checkbox)
Check the box (if applicable): Indicates the individuals to be covered are listed on the last page
of the form.
COVERAGES / LIMITS
Amount
Enter limit: The broadened personal injury protection (BPIP) limit amount.
COVERAGES / LIMITS
Medical Payments 21
Check the box (if applicable): Indicates any auto is covered.
COVERAGES / LIMITS
Medical Payments 22
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Medical Payments 23
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Medical Payments 24
Check the box (if applicable): Indicates owned autos other than private passenger autos are
covered.
COVERAGES / LIMITS
Medical Payments 27
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Medical Payments 28
Check the box (if applicable): Indicates only hired autos are covered.
COVERAGES / LIMITS
Medical Payments 29
Check the box (if applicable): Indicates non-owned autos used in garage business are covered.
COVERAGES / LIMITS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or
enter a company-unique symbol if applicable.
COVERAGES / LIMITS
Limits ($)
Enter limit: The medical payments per person limit.
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COVERAGES / LIMITS
Uninsured
Motorists-Stacked
(Checkbox)
Check the box (if applicable): Indicates the uninsured motorists coverage is stacked.
COVERAGES / LIMITS
Non-Stkd (Checkbox)
Check the box (if applicable): Indicates the uninsured motorists coverage is not stacked.
COVERAGES / LIMITS
Uninsured Motorist 22
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Uninsured Motorist 23
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Uninsured Motorist 24
Check the box (if applicable): Indicates owned autos other than private passenger autos are
covered.
COVERAGES / LIMITS
Uninsured Motorist 26
Check the box (if applicable): Indicates owned autos subject to uninsured motorists law are
covered.
COVERAGES / LIMITS
Uninsured Motorist 27
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or
enter a company-unique symbol if applicable.
COVERAGES / LIMITS
CSL (Checkbox)
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
COVERAGES / LIMITS
BI EA PER (Checkbox)
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on
the coverage.
COVERAGES / LIMITS
Amount
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by
state. (in some states this may contain the combined single limit per accident limit amount.)
COVERAGES / LIMITS
BI Each Accident ($)
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may
contain the uninsured motorists combined single limit per accident limit). The use of this limit
varies by state.
COVERAGES / LIMITS
Underinsured
Motorists-Stacked
(Checkbox)
Check the box (if applicable): Indicates the underinsured motorists coverage is stacked.
COVERAGES / LIMITS
Non-Stkd (Checkbox)
Check the box (if applicable): Indicates the underinsured motorists coverage is not stacked.
COVERAGES / LIMITS
Underinsured Motorist 22
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Underinsured Motorist 23
Check the box (if applicable): Indicates only owned private passengers autos are covered.
COVERAGES / LIMITS
Underinsured Motorist 24
Check the box (if applicable): Indicates owned autos other than private passenger autos are
covered.
COVERAGES / LIMITS
Underinsured Motorist 26
Check the box (if applicable): Indicates owned autos subject to uninsured motorists law are
covered.
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COVERAGES / LIMITS
Underinsured Motorist 27
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
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
Amount
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.
PHYSICAL DAMAGE
Comp / OTC
Check the box (if applicable): Indicates the physical damage is comprehensive/other than
collision.
PHYSICAL DAMAGE
Specified Perils
Check the box (if applicable): Indicates the physical damage coverage is for specified perils.
PHYSICAL DAMAGE
Perils option field
Enter text: The codes associated with specified perils coverage. The codes are: F - Fire, F&T -
Fire and Theft, FTW - Fire, Theft and Wind, LSP - Limited Specified Perils, SP - Specified
Perils.
PHYSICAL DAMAGE
Specified Perils 22
Check the box (if applicable): Indicates all owned autos are covered.
PHYSICAL DAMAGE
Specified Perils 23
Check the box (if applicable): Indicates only owned private passengers autos are covered.
PHYSICAL DAMAGE
Specified Perils 24
Check the box (if applicable): Indicates owned autos other than private passenger autos are
covered.
PHYSICAL DAMAGE
Specified Perils 27
Check the box (if applicable): Indicates specifically described autos are covered.
PHYSICAL DAMAGE
Specified Perils 28
Check the box (if applicable): Indicates only hired autos are covered.
PHYSICAL DAMAGE
Specified Perils 31
Check the box (if applicable): Indicates autos on consignment and dealer autos are covered.
PHYSICAL DAMAGE
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
PHYSICAL DAMAGE
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or
enter a company-unique symbol if applicable.
PHYSICAL DAMAGE
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.
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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. The location number for the
physical damage coverages should correspond to a location number documented on the
ACORD 125.
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. The location number for the
physical damage coverages should correspond to a location number documented on the
ACORD 125.
PHYSICAL DAMAGE
Enter the Limits for Each
Location Three
Enter limit: The physical damage comprehensive/other than collision or specified perils limit
amount.
PHYSICAL DAMAGE
Deductible Per Auto Three
Enter deductible: The physical damage comprehensive/other than collision or specified perils
per auto deductible amount.
PHYSICAL DAMAGE
Maximum Deductible Per
Loss Three
Enter deductible: The physical damage comprehensive/other than collision or specified perils
maximum deductible per loss amount.
PHYSICAL DAMAGE
Collision 22
Check the box (if applicable): Indicates all owned autos are covered.
PHYSICAL DAMAGE
Collision 23
Check the box (if applicable): Indicates only owned private passengers autos are covered.
PHYSICAL DAMAGE
Collision 24
Check the box (if applicable): Indicates owned autos other than private passenger autos are
covered.
PHYSICAL DAMAGE
Collision 27
Check the box (if applicable): Indicates specifically described autos are covered.
PHYSICAL DAMAGE
Collision 28
Check the box (if applicable): Indicates only hired autos are covered.
PHYSICAL DAMAGE
Collision 31
Check the box (if applicable): Indicates autos on consignment and dealer autos are covered.
PHYSICAL DAMAGE
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
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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. The location number for the
physical damage coverages should correspond to a location number documented on the
ACORD 125.
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. The location number for the
physical damage coverages should correspond to a location number documented on the
ACORD 125.
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. The location number for the
physical damage coverages should correspond to a location number documented on the
ACORD 125.
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.
GARAGE KEEPERS
Legal Liability
Check the box (if applicable): Indicates the policy is to be written on a legal liability basis.
GARAGE KEEPERS
Direct Basis
Check the box (if applicable): Indicates the policy is to be written on a direct basis.
GARAGE KEEPERS
Primary
Check the box (if applicable): Indicates this policy is the primary coverage.
GARAGE KEEPERS
Excess
Check the box (if applicable): Indicates this policy is for excess coverage.
GARAGE KEEPERS
Comp / OTC
Check the box (if applicable): Indicates the garage keepers coverage is comprehensive / other
than collision.
GARAGE KEEPERS
Specified Perils
Check the box (if applicable): Indicates the garage keepers coverage is for specified perils.
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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
garage keepers 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
garage keepers coverages should correspond to a location number documented on the ACORD
125.
GARAGE KEEPERS
Enter the Limits for Each
Location Two
Enter limit: The garage keepers comprehensive / other than collision or specified perils limit
amount.
GARAGE KEEPERS
# of Autos Two
Enter number: The number of vehicles located on the premises.
GARAGE KEEPERS
Deductible Per Auto Two
Enter deductible: The garage keepers comprehensive / other than collision or specified perils
per auto deductible amount.
GARAGE KEEPERS
Maximum Deductible Per
Loss Two
Enter deductible: The garage keepers comprehensive / other than collision or specified perils
maximum deductible per loss amount.
GARAGE KEEPERS
LOC # Three
Enter number: The producer assigned number for the location. The location number for the
garage keepers 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.
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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.
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).
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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 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.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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
Rejection of Uninsured
Motorists Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected uninsured motorists coverage in its entirety.
SIGNATURE
Rejection of Underinsured
Motorists Coverage
Initial here: The named insured's initials. As used here, indicates the named insured has
rejected underinsured motorists coverage in its entirety.
SIGNATURE
Motorcycle PIP VEH #
Enter number: The producer assigned vehicle number. As used here, the vehicle number of the
motorcycle to be covered by Personal Injury Protection.
SIGNATURE
Year
Enter year: The model year of the vehicle.
ACORD 138 KY (2014/12) rev. 05-01-2014
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SIGNATURE
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
SIGNATURE
Model
Enter text: The manufacturer's model name for the vehicle.
SIGNATURE
Horsepower
Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
SIGNATURE
Motorcycle PIP VEH #
Enter number: The producer assigned vehicle number. As used here, the vehicle number of the
motorcycle to be covered by Personal Injury Protection.
SIGNATURE
Year
Enter year: The model year of the vehicle.
SIGNATURE
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
SIGNATURE
Model
Enter text: The manufacturer's model name for the vehicle.
SIGNATURE
Horsepower
Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
SIGNATURE
Named Individual
Broadened PIP - DRV #
Enter number: The number assigned to the driver by the producer. As used here, the driver
number of the individual to be covered by Broadened Personal Injury Protection.
SIGNATURE
First Name
Enter text: The named insured's given name.
SIGNATURE
Middle Initial
Enter text: The named insured's other given name initial.
SIGNATURE
Last Name
Enter text: The named insured's surname.
SIGNATURE
Named Individual
Broadened PIP - DRV #
Enter number: The number assigned to the driver by the producer. As used here, the driver
number of the individual to be covered by Broadened Personal Injury Protection.
SIGNATURE
First Name
Enter text: The named insured's given name.
SIGNATURE
Middle Initial
Enter text: The named insured's other given name initial.
SIGNATURE
Last Name
Enter text: The named insured's surname.
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. (MM/DD/YYYY)
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 138 KY (2014/12) rev. 05-01-2014
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