ACORD 138 MI (2014/12) - MICHIGAN GARAGE AND DEALERS COVERAGES / LIMITS SECTION
ACORD 138 MI (2014/12) - MICHIGAN GARAGE AND DEALERS COVERAGES / LIMITS SECTION
ACORD 138 MI, Michigan 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.
Use this form with ACORD 128, Garage and Dealers Section.
The following are the specific differences in this state:
* Additional Property Damage Liability coverage in the amount of $1,000 is a basic liability coverage option.
* Personal Injury Protection coverages have been revised to allow for unique Michigan coverages and options. Refer to your state manual.
* No property damage coverage is available under Uninsured or Underinsured Motorists.
* Several collision options are shown. Refer to your state manual.
* Statement is added indicating that an investigative consumer report containing driving record information may be obtained for each driver in the
household.
* Provision is made to allow individuals covered under the policy who are 60 years of age or older, and who have no expectation of actual income
loss in the event of an accident, to reject coverage for work loss under Personal Injury Protection coverage. Each individual eligible must sign the
application.
* A statement is added referencing the Michigan Collision Insurance Options Notice, ACORD 62 MI, which must be given to every applicant for
auto insurance in Michigan.
* A statement is added that provides the address and phone number of the Michigan Insurance Bureau.
* A statement is added indicating that a Michigan Catastrophic Claims Association (MCCA) charge will be added to the premium per vehicle.
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. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
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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.
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.
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COVERAGES / LIMITS
EA Acc ($) Auto Only
Enter limit: The liability each accident limit for garage operations auto only. For Dealers, use
this field to enter the Policy Combined Single Limit.
COVERAGES / LIMITS
Other Than Auto Only ($)
Enter limit: The liability each accident limit for garage operations other than auto only.
COVERAGES / LIMITS
Aggregate ($)
Enter limit: The liability aggregate limit for garage operations other than auto only.
COVERAGES / LIMITS
Dealers Only-Limited
Check the box (if applicable): Indicates the liability coverage is limited for dealers.
COVERAGES / LIMITS
Dealers Only-Unlimited
Check the box (if applicable): Indicates the liability coverage is unlimited for dealers.
COVERAGES / LIMITS
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
Income Level-$0-$2,999
(Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) income level is $0 -
$2,999.
COVERAGES / LIMITS
$3,000-5,999 (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) income level is
$3,000 - $5,999.
COVERAGES / LIMITS
6,000-8,999 (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) income level is
$6,000 - $8,999
COVERAGES / LIMITS
9,000-14,999 (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) income level is
$9,000 - $14,999.
COVERAGES / LIMITS
15,000-24,999 (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) income level is $15,
000 - $24,999.
COVERAGES / LIMITS
25,000 & OVER (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) income level is
$25,000 or over.
COVERAGES / LIMITS
Other (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) income level is an
amount other than those listed.
COVERAGES / LIMITS
Other field
Enter text: The description of the other personal injury protection (PIP) income level amount.
COVERAGES / LIMITS
Ded ($) field
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
COVERAGES / LIMITS
Coord WK Loss (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss
coordination option has been selected.
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COVERAGES / LIMITS
Coord Med Exp (Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) coordination medical
expense option has been selected.
COVERAGES / LIMITS
RJCT WK Loss # pers below
(Checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss has been
rejected.
COVERAGES / LIMITS
Limited Property Damage
Liability 25
Check the box (if applicable): Indicates owned autos subject to no-fault are covered.
COVERAGES / LIMITS
Limited Property Damage
Liability 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
Property Protection 25
Check the box (if applicable): Indicates owned autos subject to no-fault are covered.
COVERAGES / LIMITS
Property 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
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
Limit ($)
Enter limit: The medical payments per person limit.
COVERAGES / LIMITS
Uninsured Motorist 22
Check the box (if applicable): Indicates all owned autos are covered.
COVERAGES / LIMITS
Uninsured Motorist 23
Check the box (if applicable): Indicates only owned private passengers autos are covered.
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COVERAGES / LIMITS
Uninsured Motorist 24
Check the box (if applicable): Indicates owned autos other than private passenger autos are
covered.
COVERAGES / LIMITS
Uninsured Motorist 26
Check the box (if applicable): Indicates owned autos subject to uninsured motorists law are
covered.
COVERAGES / LIMITS
Uninsured Motorist 27
Check the box (if applicable): Indicates specifically described autos are covered.
COVERAGES / LIMITS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be used.
COVERAGES / LIMITS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage, or
enter a company-unique symbol if applicable.
COVERAGES / LIMITS
CSL (Checkbox)
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
COVERAGES / LIMITS
BI EA PER (Checkbox)
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on
the coverage.
COVERAGES / LIMITS
Amount
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by
state. (in some states this may contain the combined single limit per accident limit amount.)
COVERAGES / LIMITS
BI Each Accident ($)
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 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.
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.
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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.
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.
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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.
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.
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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
Limited Collision Applicable
(Checkbox)
Check the box (if applicable): Indicates limited collision has been selected.
PHYSICAL DAMAGE
Limited Collision
Non-Applicable (Checkbox)
Check the box (if applicable): Indicates limited collision is not applicable.
PHYSICAL DAMAGE
Broadened Collision Ded $
field
Enter deductible: The collision 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 (Checkbox)
Check the box (if applicable): Indicates the policy is to be written on a legal liability basis.
GARAGE KEEPERS
Direct Basis (Checkbox)
Check the box (if applicable): Indicates the policy is to be written on a direct basis.
GARAGE KEEPERS
Primary (Checkbox)
Check the box (if applicable): Indicates this policy is the primary coverage.
GARAGE KEEPERS
Excess (Checkbox)
Check the box (if applicable): Indicates this policy is for excess coverage.
GARAGE KEEPERS
Comp / (OTC)
Check the box (if applicable): Indicates the garage keepers coverage is comprehensive / other
than collision.
GARAGE KEEPERS
Specified Perils
Check the box (if applicable): Indicates the garage keepers coverage is for specified perils.
GARAGE KEEPERS
Perils option field
Enter text: The codes associated with specified perils coverage. The codes are: F - Fire, F&T -
Fire and Theft, FTW - Fire, Theft and Wind, LSP - Limited Specified Perils, SP - Specified
Perils.
GARAGE KEEPERS
30 (checkbox)
Check the box (if applicable): Indicates autos left for service, repairs and/or storage are
covered.
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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.
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.
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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).
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.
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GARAGE KEEPERS
Physical Damage Reporting
Period
Enter text: The timing of the reporting period if the policy will be on a Reporting basis.
Examples: Monthly, Quarterly, Semi-Annual.
GARAGE KEEPERS
Physical Damage
Non-Reporting (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
Agency Customer ID
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 Work Loss - DRV
#
Enter number: The number assigned to the driver by the producer. As used here, the driver
number of the individual waiving work loss benefits as provided under Personal Injury Protection
coverage.
SIGNATURE
Print Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
SIGNATURE
Signature
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured has waived work loss benefits as provided under personal injury
protection coverage.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
SIGNATURE
Rejection Work Loss - DRV
#
Enter number: The number assigned to the driver by the producer. As used here, the driver
number of the individual waiving work loss benefits as provided under Personal Injury Protection
coverage.
ACORD 138 MI (2014/12) rev. 05-01-2014
Page 11 of 12
SIGNATURE
Print Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
SIGNATURE
Signature
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured has waived work loss benefits as provided under personal injury
protection coverage.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
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 MI (2014/12) rev. 05-01-2014
Page 12 of 12