Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 143 (2013/09)
Transportation Section
ACORD 143, Transportation Section, addresses the basic
underwriting and rating needs for monoline or package policies with the Inland Marine
coverages of Transportation and Motor Truck Cargo Legal Liability.
This form is to be used in conjunction with ACORD 125, Commercial Insurance
Application - Applicant Information Section and ACORD 129, Vehicle Schedule. Refer to
these forms for specific information on completing them. Much of the information for this
section should match the data found within the Applicant Information Section of ACORD
125. Nevertheless, it is still important to complete it. Since many companies separate the
applications by line of business for rating purposes, not completing this part of the
application may make it difficult to keep track of the full account.
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
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.
IDENTIFICATION SECTION
Applicant / First Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
INTEREST
Common Carrier
Check the box (if applicable): Indicates the insured is a Common Carrier and has the
general right to operate as a carrier for any shipper over certain routes and for types of
non-exempt commodities.
INTEREST
Contract Carrier
Check the box (if applicable): Indicates the insured is a Contract Carrier and has the right
to haul interstate for certain customers. The trucker is limited to no more than 10 contracts.
ACORD 143 (2013/09) rev. 06-28-2013
1 of 17
Section Name
Field Name
Field and/or Section Description
INTEREST
Shipper of Owned Property
Check the box (if applicable): Indicate if an insurable interest in the property has been
shipped on owned vehicles or other vehicles while in transit by virtue of ownership.
INTEREST
Other Interest
Check the box (if applicable): Indicate if the insured's interest in the property being shipped
is other than those listed.
INTEREST
Describe Other Interest
Enter text: The description of the insured's interest in the property being shipped.
TYPE
Transportation
Check the box (if applicable): Indicates the line of business is Transportation. Applies
when insurance is desired on property owned by the applicant, whether the property is
shipped in the applicant's vehicles or in public conveyances. Provides no Legal Liability
coverage.
TYPE
Motor Truck Cargo Legal Liability
Check the box (if applicable): Indicates the line of business is Motor Truck Cargo Legal
Liability. Applies when insurance is desired on property in the care, custody or control of
the applicant, and for which the applicant is responsible as a carrier for hire.
TYPE
Open
Check the box (if applicable): Indicates if the policy is being written on an open basis,
continuous monthly reporting policy. The values change monthly, as reported.
TYPE
Annual
Check the box (if applicable): Indicates if the policy is being written on an annual basis.
The policy written with a specified term limit.
TYPE
Other
Enter text: The pertinent information regarding coverages or explain the applicant's other
interest.
OPERATIONS
Property Shipped
Enter text: The description of the property to be insured while in transit, and indicate if the
property is also produced by the applicant. This section should be used to request
Transportation Insurance, or coverage on goods owned by the applicant, whether the
goods are shipped in the applicant's own vehicles or on public conveyances. This
insurance covers property only and does not provide coverage for Legal Liability. ACORD
101, Additional Remarks Schedule may be attached if more space is required.
OPERATIONS
Points of Origin
Enter text: The description of the origination point of the property to be shipped.
OPERATIONS
Points of Destination
Enter text: The description of the destination to which the property is to be shipped.
OPERATIONS
Territory
Enter text: The description of the area of operations for transported merchandise. This
may be specific (e.g., a certain city, state or route); or general (e.g., eastern states from
Vermont to Maryland, West Coast states, Midwest, etc.). Major cities covered in the
territory should also be provided, as well as the number of drivers within the territory.
OPERATIONS
Annual Gross Sales
Enter amount: The estimated annual amount of sales.
ACORD 143 (2013/09) rev. 06-28-2013
2 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
Contract Carrier - Incoming
Enter amount: The dollar value of all yearly incoming shipments. Specify per
classification, the total annual dollar amount of incoming, outgoing or interplant cargos
shipped or received by the applicant. Complete sections that apply next to the mode of
transportation used to transport the property to be insured. As used here, the conveyance
used is a contract carrier.
OPERATIONS
Contract Carrier - Outgoing
Enter amount: The dollar value of all yearly outgoing shipments. As used here, the
conveyance used is a contract carrier.
OPERATIONS
Contract Carrier - Interplant
Enter amount: The dollar value of all yearly shipments sent between the applicant's plants.
As used here, the conveyance used is a contract carrier.
OPERATIONS
Contract Carrier - Average Value
per Shipment
Enter amount: The average value of shipments on any type of conveyance used by the
applicant. As used here, the conveyance used is a contract carrier.
OPERATIONS
Contract Carrier - Limit of Liability
Enter limit: The liability limit. Limits should be 100 percent of the maximum value carried.
As used here, the conveyance used is a contract carrier.
OPERATIONS
Contract Carrier - Bill of Lading -
Full Value Yes
Check the box (if applicable): Indicates the full value on the bill of lading is to be insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is a contract carrier.
OPERATIONS
Contract Carrier - Bill of Lading -
Full Value No
Check the box (if applicable): Indicates the full value on the bill of lading is not insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is a contract carrier.
OPERATIONS
Contract Carrier - Released Value
Enter amount: The released value of the bill of lading. As used here, the conveyance used
is a contract carrier.
OPERATIONS
Common Carrier - Incoming
Enter amount: The dollar value of all yearly incoming shipments. Specify per
classification, the total annual dollar amount of incoming, outgoing or interplant cargos
shipped or received by the applicant. Complete sections that apply next to the mode of
transportation used to transport the property to be insured. As used here, the conveyance
used is a common carrier.
OPERATIONS
Common Carrier - Outgoing
Enter amount: The dollar value of all yearly outgoing shipments. As used here, the
conveyance used is a common carrier.
OPERATIONS
Common Carrier - Interplant
Enter amount: The dollar value of all yearly shipments sent between the applicant's plants.
As used here, the conveyance used is a common carrier.
OPERATIONS
Common Carrier - Average Value
per Shipment
Enter amount: The average value of shipments on any type of conveyance used by the
applicant. As used here, the conveyance used is a common carrier.
OPERATIONS
Common Carrier - Limit of Liability
Enter limit: The liability limit. Limits should be 100 percent of the maximum value carried.
As used here, the conveyance used is a common carrier.
ACORD 143 (2013/09) rev. 06-28-2013
3 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
Common Carrier - Bill of Lading -
Full Value Yes
Check the box (if applicable): Indicates the full value on the bill of lading is to be insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is a common carrier.
OPERATIONS
Common Carrier - Bill of Lading -
Full Value No
Check the box (if applicable): Indicates the full value on the bill of lading is not insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is a common carrier.
OPERATIONS
Common Carrier - Released Value
Enter amount: The released value of the bill of lading. As used here, the conveyance used
is a common carrier.
OPERATIONS
Rail - Incoming
Enter amount: The dollar value of all yearly incoming shipments. Specify per
classification, the total annual dollar amount of incoming, outgoing or interplant cargos
shipped or received by the applicant. Complete sections that apply next to the mode of
transportation used to transport the property to be insured. As used here, the conveyance
used is rail.
OPERATIONS
Rail - Outgoing
Enter amount: The dollar value of all yearly outgoing shipments. As used here, the
conveyance used is rail.
OPERATIONS
Rail - Interplant
Enter amount: The dollar value of all yearly shipments sent between the applicant's plants.
As used here, the conveyance used is rail.
OPERATIONS
Rail - Average Value per Shipment
Enter amount: The average value of shipments on any type of conveyance used by the
applicant. As used here, the conveyance used is rail.
OPERATIONS
Rail - Limit of Liability
Enter limit: The liability limit. Limits should be 100 percent of the maximum value carried.
As used here, the conveyance used is rail.
OPERATIONS
Rail - Bill of Lading - Full Value Yes
Check the box (if applicable): Indicates the full value on the bill of lading is to be insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is rail.
OPERATIONS
Rail - Bill of Lading - Full Value No
Check the box (if applicable): Indicates the full value on the bill of lading is not insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is rail.
OPERATIONS
Rail - Released Value
Enter amount: The released value of the bill of lading. As used here, the conveyance used
is rail.
ACORD 143 (2013/09) rev. 06-28-2013
4 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
Air Carrier - Incoming
Enter amount: The dollar value of all yearly incoming shipments. Specify per
classification, the total annual dollar amount of incoming, outgoing or interplant cargos
shipped or received by the applicant. Complete sections that apply next to the mode of
transportation used to transport the property to be insured. As used here, the conveyance
used is an air carrier.
OPERATIONS
Air Carrier - Outgoing
Enter amount: The dollar value of all yearly outgoing shipments. As used here, the
conveyance used is an air carrier.
OPERATIONS
Air Carrier - Interplant
Enter amount: The dollar value of all yearly shipments sent between the applicant's plants.
As used here, the conveyance used is an air carrier.
OPERATIONS
Air Carrier - Average Value per
Shipment
Enter amount: The average value of shipments on any type of conveyance used by the
applicant. As used here, the conveyance used is an air carrier.
OPERATIONS
Air Carrier - Limit of Liability
Enter limit: The liability limit. Limits should be 100 percent of the maximum value carried.
As used here, the conveyance used is an air carrier.
OPERATIONS
Air Carrier - Bill of Lading - Full
Value Yes
Check the box (if applicable): Indicates the full value on the bill of lading is to be insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is an air carrier.
OPERATIONS
Air Carrier - Bill of Lading - Full
Value No
Check the box (if applicable): Indicates the full value on the bill of lading is not insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is an air carrier.
OPERATIONS
Air Carrier - Released Value
Enter amount: The released value of the bill of lading. As used here, the conveyance used
is an air carrier.
OPERATIONS
Other Conveyances Used
Enter text: The description of the type of conveyance used.
OPERATIONS
Other Conveyances Used -
Incoming
Enter amount: The dollar value of all yearly incoming shipments. Specify per
classification, the total annual dollar amount of incoming, outgoing or interplant cargos
shipped or received by the applicant. Complete sections that apply next to the mode of
transportation used to transport the property to be insured. As used here, the conveyance
used is other than those listed.
OPERATIONS
Other Conveyances Used -
Outgoing
Enter amount: The dollar value of all yearly outgoing shipments. As used here, the
conveyance used is other than those listed.
OPERATIONS
Other Conveyances Used -
Interplant
Enter amount: The dollar value of all yearly shipments sent between the applicant's plants.
As used here, the conveyance used is other than those listed.
OPERATIONS
Other Conveyances Used -
Average Value per Shipment
Enter amount: The average value of shipments on any type of conveyance used by the
applicant. As used here, the conveyance used is other than those listed.
ACORD 143 (2013/09) rev. 06-28-2013
5 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
Other Conveyances Used - Limit of
Liability
Enter limit: The liability limit. Limits should be 100 percent of the maximum value carried.
As used here, the conveyance used is other than those listed.
OPERATIONS
Other Conveyances Used - Bill of
Lading - Full Value Yes
Check the box (if applicable): Indicates the full value on the bill of lading is to be insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is other than those listed.
OPERATIONS
Other Conveyances Used - Bill of
Lading - Full Value No
Check the box (if applicable): Indicates the full value on the bill of lading is not insured.
The bill of lading is a written document explaining the terms of shipment. Specify the
released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per
pound). As used here, the conveyance used is other than those listed.
OPERATIONS
Other Conveyances Used -
Released Value
Enter amount: The released value of the bill of lading. As used here, the conveyance used
is other than those listed.
OPERATIONS
Owned Vehicles - Incoming
Enter amount: The dollar value of all yearly incoming shipments. Specify per
classification, the total annual dollar amount of incoming, outgoing or interplant cargos
shipped or received by the applicant. Complete sections that apply next to the mode of
transportation used to transport the property to be insured. As used here, the conveyance
used is owned vehicles.
OPERATIONS
Owned Vehicles - Outgoing
Enter amount: The dollar value of all yearly outgoing shipments. As used here, the
conveyance used is owned vehicles.
OPERATIONS
Owned Vehicles - Interplant
Enter amount: The dollar value of all yearly shipments sent between the applicant's plants.
As used here, the conveyance used is owned vehicles.
OPERATIONS
Owned Vehicles - Average Value
per Shipment
Enter amount: The average value of shipments on any type of conveyance used by the
applicant. As used here, the conveyance used is owned vehicles.
OPERATIONS
Owned Vehicles - Limit of Liability
Enter limit: The liability limit. Limits should be 100 percent of the maximum value carried.
As used here, the conveyance used is owned vehicles.
OPERATIONS
Total - Incoming
Enter amount: The dollar value of all yearly incoming shipments. Specify per
classification, the total annual dollar amount of incoming, outgoing or interplant cargos
shipped or received by the applicant. Complete sections that apply next to the mode of
transportation used to transport the property to be insured. As used here, this is the total
amount.
OPERATIONS
Total - Outgoing
Enter amount: The dollar value of all yearly outgoing shipments. As used here, this is the
total amount.
OPERATIONS
Total - Interplant
Enter amount: The dollar value of all yearly shipments sent between the applicant's plants.
As used here, this is the total amount.
ACORD 143 (2013/09) rev. 06-28-2013
6 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
Total - Average Value per
Shipment
Enter amount: The average value of shipments on any type of conveyance used by the
applicant. As used here, this is the total amount.
OPERATIONS
Total - Limit of Liability
Enter limit: The liability limit. Limits should be 100 percent of the maximum value carried.
As used here, this is the total amount.
OPERATIONS
Perils - Special Form
Check the box (if applicable): Indicates the coverage is to be written on a special form
basis.
OPERATIONS
Perils - Named Perils
Check the box (if applicable): Indicates the coverage is to be written on a named perils
basis.
OPERATIONS
Perils - Including Theft
Check the box (if applicable): Indicates the coverage is to be written on a named perils
including theft basis.
OPERATIONS
Deductible
Enter deductible: The deductible amount for the coverage.
OPERATIONS
# Trucks Operated
Enter number: The exact number of trucks used or operated by the applicant.
OPERATIONS
# Tractors Operated
Enter number: The exact number of tractors used or operated by the applicant.
OPERATIONS
# Trailers Operated
Enter number: The exact number of trailers used or operated by the applicant.
OPERATIONS
# Tank Trucks Operated
Enter number: The exact number of tank trucks used or operated by the applicant.
OPERATIONS
# Refrigerated Units Operated
Enter number: The exact number of refrigerated trucks used or operated by the applicant.
OPERATIONS
Special Units Owned/Operated
Enter text: The description of all other vehicles owned or operated by the applicant for
which this insurance applies (e.g., extra-wide or extra-long or large tank trucks, mobile
cranes, tandem trailers and house movers). ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
VEHICLE SCHEDULE
Veh # One
Enter number: The producer assigned vehicle number. As used here, this is the number
assigned by the agent to this vehicle to track during the application process. Use this
section to identify vehicles which transport property of the applicant. This section can be
supplemented by ACORD 129, Vehicle Schedule, which highlights important features
related to this coverage line. Not all information found in the Vehicle Schedule is
necessary to complete this application.
VEHICLE SCHEDULE
Year One
Enter year: The model year of the vehicle.
VEHICLE SCHEDULE
Vehicle Make One
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE SCHEDULE
Vehicle Model One
Enter text: The manufacturer's model name for the vehicle.
VEHICLE SCHEDULE
Body Type One
Enter code: The body type of the vehicle.
VEHICLE SCHEDULE
V.I.N. One
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE SCHEDULE
Date Purchased One
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE SCHEDULE
New One
Check the box (if applicable): Indicates the vehicle was purchased new.
VEHICLE SCHEDULE
Used One
Check the box (if applicable): Indicates the vehicle was purchased used.
ACORD 143 (2013/09) rev. 06-28-2013
7 of 17
Section Name
Field Name
Field and/or Section Description
VEHICLE SCHEDULE
Radius of Operations One
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE SCHEDULE
Veh # Two
Enter number: The producer assigned vehicle number.
VEHICLE SCHEDULE
Year Two
Enter year: The model year of the vehicle.
VEHICLE SCHEDULE
Vehicle Make Two
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE SCHEDULE
Vehicle Model Two
Enter text: The manufacturer's model name for the vehicle.
VEHICLE SCHEDULE
Body Type Two
Enter code: The body type of the vehicle.
VEHICLE SCHEDULE
V.I.N. Two
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE SCHEDULE
Date Purchased Two
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE SCHEDULE
New Two
Check the box (if applicable): Indicates the vehicle was purchased new.
VEHICLE SCHEDULE
Used Two
Check the box (if applicable): Indicates the vehicle was purchased used.
VEHICLE SCHEDULE
Radius of Operations Two
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE SCHEDULE
Veh # Three
Enter number: The producer assigned vehicle number.
VEHICLE SCHEDULE
Year Three
Enter year: The model year of the vehicle.
VEHICLE SCHEDULE
Vehicle Make Three
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE SCHEDULE
Vehicle Model Three
Enter text: The manufacturer's model name for the vehicle.
VEHICLE SCHEDULE
Body Type Three
Enter code: The body type of the vehicle.
VEHICLE SCHEDULE
V.I.N. Three
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE SCHEDULE
Date Purchased Three
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE SCHEDULE
New Three
Check the box (if applicable): Indicates the vehicle was purchased new.
VEHICLE SCHEDULE
Used Three
Check the box (if applicable): Indicates the vehicle was purchased used.
VEHICLE SCHEDULE
Radius of Operations Three
Enter number: The radius in whole numbers within which this vehicle is operated.
F.O.B.
Is Contingent Coverage Desired on
F.O.B. Shipments Made by the
Applicant? Yes
Check the box (if applicable): Indicates there is contingent coverage desired on F.O.B.
shipments made by the applicant. If materials are shipped F.O.B. (Free on Board) point of
destination, the seller is liable for damages caused during transportation. If materials are
shipped F.O.B. point of departure, the buyer is liable for damages. Indicate if contingent
coverage is desired on F.O.B. shipments. Contingent coverage is either in excess of or
in lieu of coverage provided by the shipper and affords protection when the shipper's
insurance is incorrect or inadequate, or when differences in conditions (DIC) exist.
F.O.B.
Is Contingent Coverage Desired on
F.O.B. Shipments Made by the
Applicant? No
Check the box (if applicable): Indicates contingent coverage is not desired on F.O.B.
shipments made by the applicant.
ACORD 143 (2013/09) rev. 06-28-2013
8 of 17
Section Name
Field Name
Field and/or Section Description
F.O.B.
If Yes, Enter Percentage of
Annual Gross Sales Represented
by F.O.B. Shipments
Enter percentage: The percentage of annual gross sales represented by F.O.B.
shipments.
GENERAL INFORMATION
1. Is there a vehicle maintenance
program in operation? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there a
vehicle maintenance program in operation?.
GENERAL INFORMATION
1. Is there a vehicle maintenance
program in operation? No
Check the box (if applicable): Indicates a No response to the question, Is there a vehicle
maintenance program in operation?.
GENERAL INFORMATION
2. Does applicant obtain MVR
verification for drivers? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
obtain MVR verification for drivers?.
GENERAL INFORMATION
2. Does applicant obtain MVR
verification for drivers? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
obtain MVR verification for drivers?.
GENERAL INFORMATION
3. Does applicant have a driver
recruiting method? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
have a driver recruiting method?.
GENERAL INFORMATION
3. Does applicant have a driver
recruiting method? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
have a driver recruiting method?.
GENERAL INFORMATION
4. Do drivers receive a regular
physical? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do drivers
receive regular physicals?.
GENERAL INFORMATION
4. Do drivers receive a regular
physical? No
Check the box (if applicable): Indicates a No response to the question, Do drivers
receive regular physicals?.
GENERAL INFORMATION
5. Any waterborne shipments to be
covered? Yes
Check the box (if applicable): Indicates a Yes response to the question, Any waterborne
shipments to be covered?.
GENERAL INFORMATION
5. Any waterborne shipments to be
covered? No
Check the box (if applicable): Indicates a No response to the question, Any waterborne
shipments to be covered?.
GENERAL INFORMATION
6. Are vehicles equipped with theft
alarms? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are vehicles
equipped with theft alarms?.
GENERAL INFORMATION
6. Are vehicles equipped with theft
alarms? No
Check the box (if applicable): Indicates a No response to the question, Are vehicles
equipped with theft alarms?.
GENERAL INFORMATION
7. Are vehicles left unlocked when
unattended? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are vehicles left
unlocked when unattended?.
GENERAL INFORMATION
7. Are vehicles left unlocked when
unattended? No
Check the box (if applicable): Indicates a No response to the question, Are vehicles left
unlocked when unattended?.
GENERAL INFORMATION
8. Are vehicles left loaded
overnight? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are vehicles left
loaded overnight?.
ACORD 143 (2013/09) rev. 06-28-2013
9 of 17
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
8. Are vehicles left loaded
overnight? No
Check the box (if applicable): Indicates a No response to the question, Are vehicles left
loaded overnight?.
GENERAL INFORMATION
9. Does applicant back haul
property of others? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
back haul property of others?.
GENERAL INFORMATION
9. Does applicant back haul
property of others? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
back haul property of others?.
GENERAL INFORMATION
REMARKS
Enter text: The general remarks associated with the commercial inland marine line of
business. Use this section to provide any additional information required for underwriting
or rating.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
OPERATIONS
Property Hauled
Enter text: The description of property of others hauled by the applicant. This section is
used to request Motor Truck Cargo Legal Liability insurance, or coverage on property in
the care, custody or control of the applicant, for which the applicant is responsible as a
carrier for hire.
OPERATIONS
Gross Receipts Last 12 Months
Enter amount: The gross amount of sales for the past 12 months.
OPERATIONS
Gross Receipts Next 12 Months
Enter amount: The estimated gross amount of sales for the next 12 months.
OPERATIONS
Territory
Enter text: The description of the area of operations for transported merchandise. This
may be specific (e.g., a certain city, state or route); or general (e.g., eastern states from
Vermont to Maryland, West Coast states, Midwest, etc.). Major cities covered in the
territory should also be provided, as well as the number of drivers within the territory.
OPERATIONS
Average Distance
Enter number: The average distance, in miles, the applicant hauls.
OPERATIONS
Maximum Distance
Enter number: The farthest distance, in miles, the applicant hauls.
OPERATIONS
List Target Commodities Carried
One
Enter text: The description of all property hauled which might be exposed to additional risk,
including pharmaceuticals, stereos, computers, meat, seafood, televisions, audio-visual
equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing
and furs.
OPERATIONS
Percent of Gross Revenues One
Enter percentage: The percent of gross revenues earned from transporting each target
commodity.
OPERATIONS
Maximum Value per Vehicle One
Enter amount: The maximum value of each target commodity carried on any one vehicle.
OPERATIONS
List Target Commodities Carried
Two
Enter text: The description of all property hauled which might be exposed to additional risk,
including pharmaceuticals, stereos, computers, meat, seafood, televisions, audio-visual
equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing
and furs.
ACORD 143 (2013/09) rev. 06-28-2013
10 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
Percent of Gross Revenues Two
Enter percentage: The percent of gross revenues earned from transporting each target
commodity.
OPERATIONS
Maximum Value per Vehicle Two
Enter amount: The maximum value of each target commodity carried on any one vehicle.
OPERATIONS
List Target Commodities Carried
Three
Enter text: The description of all property hauled which might be exposed to additional risk,
including pharmaceuticals, stereos, computers, meat, seafood, televisions, audio-visual
equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing
and furs.
OPERATIONS
Percent of Gross Revenues Three
Enter percentage: The percent of gross revenues earned from transporting each target
commodity.
OPERATIONS
Maximum Value per Vehicle Three
Enter amount: The maximum value of each target commodity carried on any one vehicle.
OPERATIONS
List Target Commodities Carried
Four
Enter text: The description of all property hauled which might be exposed to additional risk,
including pharmaceuticals, stereos, computers, meat, seafood, televisions, audio-visual
equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing
and furs.
OPERATIONS
Percent of Gross Revenues Four
Enter percentage: The percent of gross revenues earned from transporting each target
commodity.
OPERATIONS
Maximum Value per Vehicle Four
Enter amount: The maximum value of each target commodity carried on any one vehicle.
OPERATIONS
List Target Commodities Carried
Five
Enter text: The description of all property hauled which might be exposed to additional risk,
including pharmaceuticals, stereos, computers, meat, seafood, televisions, audio-visual
equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing
and furs.
OPERATIONS
Percent of Gross Revenues Five
Enter percentage: The percent of gross revenues earned from transporting each target
commodity.
OPERATIONS
Maximum Value per Vehicle Five
Enter amount: The maximum value of each target commodity carried on any one vehicle.
OPERATIONS
List Target Commodities Carried
Six
Enter text: The description of all property hauled which might be exposed to additional risk,
including pharmaceuticals, stereos, computers, meat, seafood, televisions, audio-visual
equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing
and furs.
OPERATIONS
Percent of Gross Revenues Six
Enter percentage: The percent of gross revenues earned from transporting each target
commodity.
OPERATIONS
Maximum Value per Vehicle Six
Enter amount: The maximum value of each target commodity carried on any one vehicle.
ACORD 143 (2013/09) rev. 06-28-2013
11 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
List Target Commodities Carried
Seven
Enter text: The description of all property hauled which might be exposed to additional risk,
including pharmaceuticals, stereos, computers, meat, seafood, televisions, audio-visual
equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing
and furs.
OPERATIONS
Percent of Gross Revenues Seven
Enter percentage: The percent of gross revenues earned from transporting each target
commodity.
OPERATIONS
Maximum Value per Vehicle Seven
Enter amount: The maximum value of each target commodity carried on any one vehicle.
OPERATIONS
State Filings Required
Enter text: The list of all states requiring filings for the regulation of the trucking industry.
Indicate if a P.U.C. (Public Utility Commission), P.S.C. (Public Safety Commission) or
I.C.C. (Interstate Commerce Commission) filing is required. Enter all known docket
numbers for these filings
OPERATIONS
Docket No. Checkbox
Check the box (if applicable): Indicates a docket number has been assigned.
OPERATIONS
Docket No. Description
Enter identifier: The cargo docket number.
OPERATIONS
I.C.C. Filing Required
Check the box (if applicable): Indicates an Interstate Commerce Commission (ICC) filing is
required.
OPERATIONS
Docket No.
Enter identifier: The cargo docket number assigned by the Interstate Commerce
Commission (ICC).
OPERATIONS
Limit of Liability - Per Single
Conveyance
Enter limit: The limit per conveyance which is the aggregate limit being moved by a
motorized unit (e.g., truck with semi-trailer or full trailers). As used here, enter the amount
of insurance required for each applicable category. If different limits exist for different
vehicles, show the limits of liability per vehicle in the Remarks section. ACORD 101,
Additional Remarks Schedule may be attached if more space is required.
OPERATIONS
Per Disaster
Enter limit: The overall disaster limit.
OPERATIONS
Loading/Unloading
Check the box (if applicable): Indicates loading or unloading coverage is desired.
OPERATIONS
Limit
Enter limit: The limit amount for loading or unloading coverage.
OPERATIONS
Deductible
Enter deductible: The deductible amount for loading or unloading coverage.
OPERATIONS
Perils - Special Form
Check the box (if applicable): Indicates the coverage is to be written on a special form
basis.
OPERATIONS
Named Perils
Check the box (if applicable): Indicates the coverage is to be written on a named perils
basis.
OPERATIONS
Including Theft
Check the box (if applicable): Indicates the coverage is to be written on a named perils
including theft basis.
OPERATIONS
Loading/Unloading
Check the box (if applicable): Indicates the coverage is to be written on a named perils
loading / unloading basis.
ACORD 143 (2013/09) rev. 06-28-2013
12 of 17
Section Name
Field Name
Field and/or Section Description
OPERATIONS
Deductible
Enter deductible: The deductible amount for the coverage.
OPERATIONS
# Trucks Operated
Enter number: The exact number of trucks used or operated by the applicant.
OPERATIONS
# Tractors Operated
Enter number: The exact number of tractors used or operated by the applicant.
OPERATIONS
# Trailers Operated
Enter number: The exact number of trailers used or operated by the applicant.
OPERATIONS
# Tank Trucks Operated
Enter number: The exact number of tank trailers used or operated by the applicant.
OPERATIONS
# Refrigerated Units Operated
Enter number: The exact number of refrigerated trucks used or operated by the applicant.
OPERATIONS
Special Units Owned/Operated
Enter text: The description of all other vehicles owned or operated by the applicant for
which this insurance applies (e.g., extra-wide or extra-long or large tank trucks, mobile
cranes, tandem trailers and house movers). ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
TERMINALS
Location # One
Enter number: The producer assigned number of the location. As used here, if locations
are the same as shown on the Applicant Information Section (ACORD 125), use the same
number in the space provided. Terminal locations are buildings (or enclosed areas)
owned or used by the applicant and operated as points of holding, distribution,
warehousing, or layovers for property off vehicles.
TERMINALS
Address One
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The second address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter text: The county of the location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
Average Value At Terminal One
Enter amount: The average value of goods held at the terminal location.
TERMINALS
Maximum Value One
Enter amount: The maximum value of goods held at the terminal location.
TERMINALS
Limit of Liability One
Enter limit: The limit required for the terminal location. The limit should be 100 percent of
the maximum value carried.
TERMINALS
Location # Two
Enter number: The producer assigned number of the location.
TERMINALS
Address Two
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The second address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter text: The county of the location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
Average Value At Terminal Two
Enter amount: The average value of goods held at the terminal location.
TERMINALS
Maximum Value Two
Enter amount: The maximum value of goods held at the terminal location.
ACORD 143 (2013/09) rev. 06-28-2013
13 of 17
Section Name
Field Name
Field and/or Section Description
TERMINALS
Limit of Liability Two
Enter limit: The limit required for the terminal location. The limit should be 100 percent of
the maximum value carried.
TERMINALS
Location # Three
Enter number: The producer assigned number of the location.
TERMINALS
Address Three
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The second address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter text: The county of the location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
Average Value At Terminal Three
Enter amount: The average value of goods held at the terminal location.
TERMINALS
Maximum Value Three
Enter amount: The maximum value of goods held at the terminal location.
TERMINALS
Limit of Liability Three
Enter limit: The limit required for the terminal location. The limit should be 100 percent of
the maximum value carried.
VEHICLE SCHEDULE
Veh # One
Enter number: The producer assigned vehicle number. As used here, use this section to
identify vehicles used by the applicant to transport property of others. This section can be
supplemented by the ACORD Vehicle Schedule (ACORD 129), and highlights important
features found in the ACORD Vehicle Schedule related to this line of coverage. Not all
information found in the ACORD Vehicle Schedule is necessary to complete this
application.
VEHICLE SCHEDULE
Year One
Enter year: The model year of the vehicle.
VEHICLE SCHEDULE
Vehicle Make One
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE SCHEDULE
Vehicle Model One
Enter text: The manufacturer's model name for the vehicle.
VEHICLE SCHEDULE
Body Type One
Enter code: The body type of the vehicle.
VEHICLE SCHEDULE
V.I.N. One
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE SCHEDULE
Date Purchased One
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE SCHEDULE
New One
Check the box (if applicable): Indicates the vehicle was purchased new.
VEHICLE SCHEDULE
Used One
Check the box (if applicable): Indicates the vehicle was purchased used.
VEHICLE SCHEDULE
Radius of Operations One
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE SCHEDULE
Veh # Two
Enter number: The producer assigned vehicle number.
VEHICLE SCHEDULE
Year Two
Enter year: The model year of the vehicle.
VEHICLE SCHEDULE
Vehicle Make Two
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE SCHEDULE
Vehicle Model Two
Enter text: The manufacturer's model name for the vehicle.
VEHICLE SCHEDULE
Body Type Two
Enter code: The body type of the vehicle.
ACORD 143 (2013/09) rev. 06-28-2013
14 of 17
Section Name
Field Name
Field and/or Section Description
VEHICLE SCHEDULE
V.I.N. Two
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE SCHEDULE
Date Purchased Two
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE SCHEDULE
New Two
Check the box (if applicable): Indicates the vehicle was purchased new.
VEHICLE SCHEDULE
Used Two
Check the box (if applicable): Indicates the vehicle was purchased used.
VEHICLE SCHEDULE
Radius of Operations Two
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE SCHEDULE
Veh # Three
Enter number: The producer assigned vehicle number.
VEHICLE SCHEDULE
Year Three
Enter year: The model year of the vehicle.
VEHICLE SCHEDULE
Vehicle Make Three
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE SCHEDULE
Vehicle Model Three
Enter text: The manufacturer's model name for the vehicle.
VEHICLE SCHEDULE
Body Type Three
Enter code: The body type of the vehicle.
VEHICLE SCHEDULE
V.I.N. Three
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE SCHEDULE
Date Purchased Three
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE SCHEDULE
New Three
Check the box (if applicable): Indicates the vehicle was purchased new.
VEHICLE SCHEDULE
Used Three
Check the box (if applicable): Indicates the vehicle was purchased used.
VEHICLE SCHEDULE
Radius of Operations Three
Enter number: The radius in whole numbers within which this vehicle is operated.
GENERAL INFORMATION
1. Is there a vehicle maintenance
program in operation? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there a
vehicle maintenance program in operation?.
GENERAL INFORMATION
1. Is there a vehicle maintenance
program in operation? No
Check the box (if applicable): Indicates a No response to the question, Is there a vehicle
maintenance program in operation?.
GENERAL INFORMATION
2. Does applicant obtain MVR
verification for drivers? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
obtain MVR verification for drivers?.
GENERAL INFORMATION
2. Does applicant obtain MVR
verification for drivers? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
obtain MVR verification for drivers?.
GENERAL INFORMATION
3. Does applicant have a driver
recruiting method? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
have a driver recruiting method?.
GENERAL INFORMATION
3. Does applicant have a driver
recruiting method? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
have a driver recruiting method?.
GENERAL INFORMATION
4. Do drivers receive a regular
physical? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do drivers
receive regular physicals?.
GENERAL INFORMATION
4. Do drivers receive a regular
physical? No
Check the box (if applicable): Indicates a No response to the question, Do drivers
receive regular physicals?.
ACORD 143 (2013/09) rev. 06-28-2013
15 of 17
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
5. Are vehicles equipped with theft
alarms? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are vehicles
equipped with theft alarms?.
GENERAL INFORMATION
5. Are vehicles equipped with theft
alarms? No
Check the box (if applicable): Indicates a No response to the question, Are vehicles
equipped with theft alarms?.
GENERAL INFORMATION
6. Are vehicles left unlocked when
unattended? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are vehicles left
unlocked when unattended?.
GENERAL INFORMATION
6. Are vehicles left unlocked when
unattended? No
Check the box (if applicable): Indicates a No response to the question, Are vehicles left
unlocked when unattended?.
GENERAL INFORMATION
7. Are overages, shortages and
damage claims pending? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are overages,
shortages, & damage claims pending?.
GENERAL INFORMATION
7. Are overages, shortages and
damage claims pending? No
Check the box (if applicable): Indicates a No response to the question, Are overages,
shortages, & damage claims pending?.
GENERAL INFORMATION
8. Are any vehicles operated for
the applicant by others? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any
vehicles operated for the applicant by others?.
GENERAL INFORMATION
8. Are any vehicles operated for
the applicant by others? No
Check the box (if applicable): Indicates a No response to the question, Are any vehicles
operated for the applicant by others?.
GENERAL INFORMATION
9. Do terminals have fire protection
(sprinklers, hoses, etc.)? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do terminals
have fire protection (sprinklers, hoses, etc.)?.
GENERAL INFORMATION
9. Do terminals have fire protection
(sprinklers, hoses, etc.)? No
Check the box (if applicable): Indicates a No response to the question, Do terminals
have fire protection (sprinklers, hoses, etc.)?.
GENERAL INFORMATION
10. Do terminals have security
systems (guards, alarms, fences,
lights, dogs,
etc.)? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do terminals
have security systems (guards, alarms, fences, lights, dogs, etc.)?.
GENERAL INFORMATION
10. Do terminals have security
systems (guards, alarms, fences,
lights, dogs,
etc.)? No
Check the box (if applicable): Indicates a No response to the question, Do terminals
have security systems (guards, alarms, fences, lights, dogs, etc.)?.
GENERAL INFORMATION
11. Are vehicles left loaded
overnight? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are vehicles left
loaded overnight?.
GENERAL INFORMATION
11. Are vehicles left loaded
overnight? No
Check the box (if applicable): Indicates a No response to the question, Are vehicles left
loaded overnight?.
GENERAL INFORMATION
12. Is applicant an owner
operator? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is the applicant
an owner operator?.
ACORD 143 (2013/09) rev. 06-28-2013
16 of 17
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
12. Is applicant an owner
operator? No
Check the box (if applicable): Indicates a No response to the question, Is the applicant
an owner operator?.
GENERAL INFORMATION
13. Does the applicant hire owner
operators? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does the
applicant hire owner operators?.
GENERAL INFORMATION
13. Does the applicant hire owner
operators? No
Check the box (if applicable): Indicates a No response to the question, Does the
applicant hire owner operators?.
GENERAL INFORMATION
14. Does the applicant triplease to
others? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does the
applicant triplease to others?.
GENERAL INFORMATION
14. Does the applicant triplease to
others? No
Check the box (if applicable): Indicates a No response to the question, Does the
applicant triplease to others?.
GENERAL INFORMATION
15. Does the applicant back haul
property of others? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
back haul property of others?.
GENERAL INFORMATION
15. Does the applicant back haul
property of others? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
back haul property of others?.
GENERAL INFORMATION
REMARKS
Enter text: The general remarks associated with the commercial inland marine line of
business. Use this section to provide any additional information required for underwriting
or rating.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
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
Producer's Name (Please Print)
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
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
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.
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
ACORD 143 (2013/09) rev. 06-28-2013
17 of 17