ACORD 132 (2014/12) - Truckers / Motor Carriers Section

ACORD 132 (2014/12) - Truckers / Motor Carriers Section
ACORD 132, Truckers / Motor Carriers Section, has been designed to handle the basic underwriting and rating needs for liability and physical
damage coverages for trucking or motor carrier operations. If a transportation or motor truck legal liability exposure exists, the Transportation
Section, ACORD 143, may also need to be completed.
Insurance coverages, no fault and uninsured / underinsured motorists coverages in particular, vary widely from state to state. In addition, there
are numerous state-specific requirements that apply to Truckers or Motor Carrier applications. ACORD 132 cannot address these various unique
specifications. Therefore, state specific forms, ACORD 137s, have been developed to respond to these requirements. Use the ACORD 137 for
your state to provide coverages / limits information, as well as the required disclosure and other data unique to the state. See the specific state
forms FIG for more information.
This form was designed to be used in conjunction with ACORD 125, Commercial Insurance Application, Applicant Information Section and ACORD
129, Vehicle Schedule. Please see the FIG for these forms for specific information on completing them.
Many states require supplements to all auto applications, to provide specific coverage explanations or to allow applicants to accept or reject certain
coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of
information pertinent to auto insurance.
ACORD has provided the necessary supplements in all states.
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.
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
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
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
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Page 1 of 26
PRINCIPAL SHIPPERS
Principal Shippers
Enter text: The name of a shipper frequently serviced by the applicant / insured.
PRINCIPAL SHIPPERS
Enter text: The name of a shipper frequently serviced by the applicant / insured.
PRINCIPAL SHIPPERS
Enter text: The name of a shipper frequently serviced by the applicant / insured.
PRINCIPAL SHIPPERS
Enter text: The name of a shipper frequently serviced by the applicant / insured.
REGULATION
Common Carrier
Check the box (if applicable): Indicates the relationship between the applicant and the property
being shipped is as a common carrier and has the general rights to operate as a carrier for any
shipper over certain routes and for types of non-exempt commodities.
REGULATION
Contract Carrier
Check the box (if applicable): Indicates the relationship between the applicant and the property
being shipped is as a contract carrier and has the rights to haul interstate for certain specific
customers. The trucker is limited to no more than 10 contracts.
REGULATION
Private Carrier
Check the box (if applicable): Indicates an insurable interest in the property being shipped on
owned vehicles or other vehicles while in transit by virtue of ownership.
REGULATION
DOT (Department of
Transportation) Rating
Check the box (if applicable): Indicates if DOT rating applies to this policy.
REGULATION
Docket #
Check the box (if applicable): Indicates a docket number has been assigned.
REGULATION
Docket #
Enter identifier: The DOT docket number.
REGULATION
ICC Filing
Check the box (if applicable): Indicates an Interstate Commerce Commission (ICC) filing is
required.
REGULATION
Docket #
Enter identifier: The cargo docket number assigned by the Interstate Commerce Commission
(ICC).
RECEIPTS, MILEAGE UNITS
Next Year Gross Receipts
Enter amount: The annual gross receipts amount. As used here, this information is for next
year.
RECEIPTS, MILEAGE UNITS
Next Year Total Mileage
Enter number: The estimated annual mileage for all vehicles. As used here, this information is
for next year.
RECEIPTS, MILEAGE UNITS
Next Year # Power Units
Enter number: The total number of power units. As used here, this information is for next year.
RECEIPTS, MILEAGE UNITS
Past Year Gross Receipts
Enter amount: The annual gross receipts amount. As used here, this information is for the past
year.
RECEIPTS, MILEAGE UNITS
Past Year Total Mileage
Enter number: The estimated annual mileage for all vehicles. As used here, this information is
for the past year.
RECEIPTS, MILEAGE UNITS
Past Year # Power Units
Enter number: The total number of power units. As used here, this information is for the past
year.
RECEIPTS, MILEAGE UNITS
Prev Year One Gross
Receipts
Enter amount: The annual gross receipts amount. As used here, this information is for two years
ago.
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RECEIPTS, MILEAGE UNITS
Prev Year One Total Mileage
Enter number: The estimated annual mileage for all vehicles. As used here, this information is
for two years ago.
RECEIPTS, MILEAGE UNITS
Prev Year One # Power
Units
Enter number: The total number of power units. As used here, this information is for two years
ago.
RECEIPTS, MILEAGE UNITS
Prev Year Two Gross
Receipts
Enter amount: The annual gross receipts amount. As used here, this information is for three
years ago.
RECEIPTS, MILEAGE UNITS
Prev Year Two Total Mileage
Enter number: The estimated annual mileage for all vehicles. As used here, this information is
for three years ago.
RECEIPTS, MILEAGE UNITS
Prev Year Two# Power Units
Enter number: The total number of power units. As used here, this information is for three years
ago.
COMMODITIES
Commodities Transported
Enter text: The description of the type of commodity being transported.
COMMODITIES
% Total Revenue
Enter percentage: The percentage of total revenues attributed to the commodity.
COMMODITIES
Value Per Truckload
Enter amount: The estimated value of the commodity per truckload.
COMMODITIES
Commodities Transported
Enter text: The description of the type of commodity being transported.
COMMODITIES
% Total Revenue
Enter percentage: The percentage of total revenues attributed to the commodity.
COMMODITIES
Value Per Truckload
Enter amount: The estimated value of the commodity per truckload.
COMMODITIES
Commodities Transported
Enter text: The description of the type of commodity being transported.
COMMODITIES
% Total Revenue
Enter percentage: The percentage of total revenues attributed to the commodity.
COMMODITIES
Value Per Truckload
Enter amount: The estimated value of the commodity per truckload.
COMMODITIES
Commodities Transported
Enter text: The description of the type of commodity being transported.
COMMODITIES
% Total Revenue
Enter percentage: The percentage of total revenues attributed to the commodity.
COMMODITIES
Value Per Truckload
Enter amount: The estimated value of the commodity per truckload.
TERMINALS
Loc # One
Enter number: The producer assigned number of the location.
TERMINALS
Zone # One
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals One
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
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TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh One
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage One
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Two
Enter number: The producer assigned number of the location.
TERMINALS
Zone # Two
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Two
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Two
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Two
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Three
Enter number: The producer assigned number of the location.
TERMINALS
Zone # Three
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Three
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Three
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Three
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Four
Enter number: The producer assigned number of the location.
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TERMINALS
Zone # Four
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Four
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Four
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Four
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Five
Enter number: The producer assigned number of the location.
TERMINALS
Zone # Five
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Five
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Five
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Five
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Six
Enter number: The producer assigned number of the location.
TERMINALS
Zone # Six
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Six
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
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TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Six
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Six
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Seven
Enter number: The producer assigned number of the location.
TERMINALS
Zone # Seven
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Seven
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Seven
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Seven
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Eight
Enter number: The producer assigned number of the location.
TERMINALS
Zone # Eight
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Eight
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Eight
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Eight
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Nine
Enter number: The producer assigned number of the location.
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TERMINALS
Zone # Nine
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Nine
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Nine
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Nine
Enter number: The approximate distance between the terminal and the place of principal
garaging.
TERMINALS
Loc # Ten
Enter number: The producer assigned number of the location.
TERMINALS
Zone # Ten
Enter code: The Insurance Services Organization industry code (ISO Zone Code) that identifies
the area serviced from this location.
TERMINALS
Name and Address of
Terminals Ten
Enter text: The full name of the location.
TERMINALS
Enter text: The first address line of the physical location.
TERMINALS
Enter text: The city of the physical location.
TERMINALS
Enter code: The state or province of the physical location.
TERMINALS
Enter code: The postal code of the physical location.
TERMINALS
# Veh Ten
Enter number: The number of vehicles regularly using or garaged at this terminal.
TERMINALS
Dist. From Garage Ten
Enter number: The approximate distance between the terminal and the place of principal
garaging.
DRIVER INFORMATION
ACORD 163 attached for
additional drivers
Check the box (if applicable): Indicates that additional drivers appear on the attached ACORD
163 Commercial Auto Driver Information Schedule.
DRIVER INFORMATION
Driver # One
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name One
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Enter text: The city of the driver.
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DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex One
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat One
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union / Registered
Domestic Partner, F- Fianc / Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Date of Birth One
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp One
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed One
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License
Number/Soc. Sec. # One
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
State Lic. One
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire One
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # One
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use One
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Two
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Two
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex Two
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Two
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union / Registered
Domestic Partner, F- Fianc / Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Date of Birth Two
Enter date: The birth date of the driver. (MM/DD/YYYY)
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DRIVER INFORMATION
Yrs Exp Two
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Two
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License
Number/Soc. Sec. # Two
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
State Lic. Two
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Two
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Two
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Two
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Three
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Three
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex Three
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Three
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union / Registered
Domestic Partner, F- Fianc / Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Date of Birth Three
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Three
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Three
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License
Number/Soc. Sec. # Three
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
State Lic. Three
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Three
Enter date: The date the driver was hired.
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DRIVER INFORMATION
Use Vehicle # Three
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Three
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Four
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Four
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex Four
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Four
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union / Registered
Domestic Partner, F- Fianc / Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Date of Birth Four
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Four
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Four
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License
Number/Soc. Sec. # Four
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
State Lic. Four
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Four
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Four
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Four
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Five
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Five
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
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DRIVER INFORMATION
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex Five
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Five
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union / Registered
Domestic Partner, F- Fianc / Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Date of Birth Five
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Five
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Five
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License
Number/Soc. Sec. # Five
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
State Lic. Five
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Five
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Five
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Five
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Six
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Six
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex Six
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Six
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union / Registered
Domestic Partner, F- Fianc / Fiance, U - Unknown, O - Other
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DRIVER INFORMATION
Date of Birth Six
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Six
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Six
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License
Number/Soc. Sec. # Six
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
State Lic. Six
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Six
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Six
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Six
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
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).
EQUIPMENT
ACORD 129 Vehicle Section
attached for owned units
Check the box (if applicable): Indicates that additional vehicles appear on the attached ACORD
129.
EQUIPMENT
Trucks - Company Owned
Enter number: The number of owned trucks.
EQUIPMENT
Trucks - Non-Owned
Enter number: The number of non-owned trucks.
EQUIPMENT
Trucks - Long Term Leased
Enter number: The number of long term leased trucks.
EQUIPMENT
Trucks - Trip Lease
Enter number: The number of trip leased trucks.
EQUIPMENT
Trucks - Radius (miles) -
Local
Enter number: The number of trucks that fall within the category of local radius / distance in
accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Trucks - Radius (miles) -
Intermediate
Enter number: The number of trucks that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Trucks - Radius (miles) -
Long Distance
Enter number: The number of trucks that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
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EQUIPMENT
Trucks - Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Tractors - Company Owned
Enter number: The number of owned tractors.
EQUIPMENT
Tractors - Non-Owned
Enter number: The number of non-owned tractors.
EQUIPMENT
Tractors - Long Term
Leased
Enter number: The number of long term leased tractors.
EQUIPMENT
Tractors - Trip Lease
Enter number: The number of trip leased tractors.
EQUIPMENT
Tractors - Radius (miles) -
Local
Enter number: The number of tractors that fall within the category of local radius / distance in
accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Tractors - Radius (miles) -
Intermediate
Enter number: The number of tractors that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Tractors - Radius (miles) -
Long Distance
Enter number: The number of tractors that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
EQUIPMENT
Tractors - Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Semi-Trailers - Company
Owned
Enter number: The number of owned semi-trailers.
EQUIPMENT
Semi-Trailers - Non-Owned
Enter number: The number of non-owned semi-trailers.
EQUIPMENT
Semi-Trailers - Long Term
Leased
Enter number: The number of long term leased semi-trailers.
ACORD 132 (2014/12) rev. 04-29-2014
Page 13 of 26
EQUIPMENT
Semi-Trailers - Trip Lease
Enter number: The number of trip leased semi-trailers.
EQUIPMENT
Semi-Trailers - Radius
(miles) - Local
Enter number: The number of semi-trailers that fall within the category of local radius / distance
in accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Semi-Trailers - Radius
(miles) - Intermediate
Enter number: The number of semi-trailers that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Semi-Trailers - Radius
(miles) - Long Distance
Enter number: The number of semi-trailers that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
EQUIPMENT
Semi-Trailers -
Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Full Trailers - Company
Owned
Enter number: The number of owned full trailers.
EQUIPMENT
Full Trailers - Non-Owned
Enter number: The number of non-owned full trailers.
EQUIPMENT
Full Trailers - Long Term
Leased
Enter number: The number of long term leased full trailers.
EQUIPMENT
Full Trailers - Trip Lease
Enter number: The number of trip leased full trailers.
EQUIPMENT
Full Trailers - Radius (miles)
- Local
Enter number: The number of full trailers that fall within the category of local radius / distance in
accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Full Trailers - Radius (miles)
- Intermediate
Enter number: The number of full trailers that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Full Trailers - Radius (miles)
- Long Distance
Enter number: The number of full trailers that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
ACORD 132 (2014/12) rev. 04-29-2014
Page 14 of 26
EQUIPMENT
Full Trailers - Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Tank Semi-Trailers -
Company Owned
Enter number: The number of owned tank semi-trailers.
EQUIPMENT
Tank Semi-Trailers -
Non-Owned
Enter number: The number of non-owned tank semi-trailers.
EQUIPMENT
Tank Semi-Trailers - Long
Term Leased
Enter number: The number of long term leased tank semi-trailers.
EQUIPMENT
Tank Semi-Trailers - Trip
Lease
Enter number: The number of trip leased tank semi-trailers.
EQUIPMENT
Tank Semi-Trailers - Radius
(miles) - Local
Enter number: The number of tank semi-trailers that fall within the category of local radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of local.
EQUIPMENT
Tank Semi-Trailers - Radius
(miles) - Intermediate
Enter number: The number of tank semi-trailers that fall within the category of intermediate
radius / distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of intermediate.
EQUIPMENT
Tank Semi-Trailers - Radius
(miles) - Long Distance
Enter number: The number of tank semi-trailers that fall within the category of long distance
radius / distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of long distance.
EQUIPMENT
Tank Semi-Trailers -
Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Tank Trailers - Company
Owned
Enter number: The number of owned tank trailers.
EQUIPMENT
Tank Trailers - Non-Owned
Enter number: The number of non-owned tank trailers.
ACORD 132 (2014/12) rev. 04-29-2014
Page 15 of 26
EQUIPMENT
Tank Trailers - Long Term
Leased
Enter number: The number of long term leased tank trailers.
EQUIPMENT
Tank Trailers - Trip Lease
Enter number: The number of trip leased tank trailers.
EQUIPMENT
Tank Trailers - Radius
(miles) - Local
Enter number: The number of tank trailers that fall within the category of local radius / distance
in accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Tank Trailers - Radius
(miles) - Intermediate
Enter number: The number of tank trailers that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Tank Trailers - Radius
(miles) - Long Distance
Enter number: The number of tank trailers that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
EQUIPMENT
Tank Trailers -
Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Refrigerated Trucks -
Company Owned
Enter number: The number of owned refrigerated trailers.
EQUIPMENT
Refrigerated Trucks -
Non-Owned
Enter number: The number of non-owned refrigerated trailers.
EQUIPMENT
Refrigerated Trucks - Long
Term Leased
Enter number: The number of long term leased refrigerated trailers.
EQUIPMENT
Refrigerated Trucks - Trip
Lease
Enter number: The number of trip leased refrigerated trailers.
EQUIPMENT
Refrigerated Trucks -
Radius (miles) - Local
Enter number: The number of refrigerated trailers that fall within the category of local radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of local.
EQUIPMENT
Refrigerated Trucks -
Radius (miles) -
Intermediate
Enter number: The number of refrigerated trailers that fall within the category of intermediate
radius / distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of intermediate.
ACORD 132 (2014/12) rev. 04-29-2014
Page 16 of 26
EQUIPMENT
Refrigerated Trucks -
Radius (miles) - Long
Distance
Enter number: The number of refrigerated trailers that fall within the category of long distance
radius / distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of long distance.
EQUIPMENT
Refrigerated Trucks
-Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Service Trucks - Company
Owned
Enter number: The number of owned service trucks.
EQUIPMENT
Service Trucks -
Non-Owned
Enter number: The number of non-owned service trucks.
EQUIPMENT
Service Trucks - Long Term
Leased
Enter number: The number of long term leased service trucks.
EQUIPMENT
Service Trucks - Trip Lease
Enter number: The number of trip leased service trucks.
EQUIPMENT
Service Trucks - Radius
(miles) - Local
Enter number: The number of service trucks that fall within the category of local radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of local.
EQUIPMENT
Service Trucks - Radius
(miles) - Intermediate
Enter number: The number of service trucks that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Service Trucks - Radius
(miles) - Long Distance
Enter number: The number of service trucks that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
EQUIPMENT
Service Trucks -
Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Private Passenger Autos -
Company Owned
Enter number: The number of owned private passenger vehicles.
ACORD 132 (2014/12) rev. 04-29-2014
Page 17 of 26
EQUIPMENT
Private Passenger Autos -
Non-Owned
Enter number: The number of non-owned private passenger vehicles.
EQUIPMENT
Private Passenger Autos -
Long Term Leased
Enter number: The number of long term leased private passenger vehicles.
EQUIPMENT
Private Passenger Autos -
Trip Lease
Enter number: The number of trip leased private passenger vehicles.
EQUIPMENT
Private Passenger Autos -
Radius (miles) - Local
Enter number: The number of private passenger vehicles that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of local..
EQUIPMENT
Private Passenger Autos -
Radius (miles) -
Intermediate
Enter number: The number of private passenger vehicles that fall within the category of
intermediate radius/distance in accordance with a company's rating rules. The Insurance
Services Office maintains the definition of intermediate.
EQUIPMENT
Private Passenger Autos -
Radius (miles) - Long
Distance
Enter number: The number of private passenger vehicles that fall within the category of long
distance radius/distance in accordance with a company's rating rules. The Insurance Services
Office maintains the definition of long distance.
EQUIPMENT
Private Passenger Autos -
Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Other - Describe
Enter text: The description of the vehicle type.
EQUIPMENT
Other - Company Owned
Enter number: The number of owned vehicles.
EQUIPMENT
Other - Non-Owned
Enter number: The number of non-owned vehicles.
EQUIPMENT
Other - Long Term Leased
Enter number: The number of long term leased vehicles.
EQUIPMENT
Other - Trip Lease
Enter number: The number of trip leased vehicles.
EQUIPMENT
Other - Radius (miles) -
Local
Enter number: The number of vehicles that fall within the category of local radius / distance in
accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Other - Radius (miles) -
Intermediate
Enter number: The number of vehicles that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
ACORD 132 (2014/12) rev. 04-29-2014
Page 18 of 26
EQUIPMENT
Other - Radius (miles) -
Long Distance
Enter number: The number of vehicles that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
EQUIPMENT
Other - Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Other - Describe
Enter text: The description of the vehicle type.
EQUIPMENT
Other - Company Owned
Enter number: The number of owned vehicles.
EQUIPMENT
Other - Non-Owned
Enter number: The number of non-owned vehicles.
EQUIPMENT
Other - Long Term Leased
Enter number: The number of long term leased vehicles.
EQUIPMENT
Other - Trip Lease
Enter number: The number of trip leased vehicles.
EQUIPMENT
Other - Radius (miles) -
Local
Enter number: The number of vehicles that fall within the category of local radius / distance in
accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Other - Radius (miles) -
Intermediate
Enter number: The number of vehicles that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Other - Radius (miles) -
Long Distance
Enter number: The number of vehicles that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
EQUIPMENT
Other - Territory/Zone
Enter text: The territory in which the applicant normally operates. This may be a certain city,
county or state. If the applicant has any special routes or areas of confined operation, so
indicate. List any specific geographic areas that the applicant may operate out of such as
Mid-Western States or East Coast.
For zone rated risks, provide the appropriate numbers or identification information. Zone rating
is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles
from the point of principal garaging. It does not apply to light trucks or trailers used with light
trucks.
EQUIPMENT
Total Vehicles - Company
Owned
Enter number: The total number of owned vehicles.
ACORD 132 (2014/12) rev. 04-29-2014
Page 19 of 26
EQUIPMENT
Total Vehicles - Non-Owned
Enter number: The total number of non-owned vehicles.
EQUIPMENT
Total Vehicles - Long Term
Leased
Enter number: The total number of long term leased vehicles.
EQUIPMENT
Total Vehicles - Trip Lease
Enter number: The total number of trip leased vehicles.
EQUIPMENT
Total Vehicles - Radius
(miles) - Local
Enter number: The total number of vehicles that fall within the category of local radius / distance
in accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
EQUIPMENT
Total Vehicles - Radius
(miles) - Intermediate
Enter number: The total number of vehicles that fall within the category of intermediate radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of intermediate.
EQUIPMENT
Total Vehicles - Radius
(miles) - Long Distance
Enter number: The total number of vehicles that fall within the category of long distance radius /
distance in accordance with a company's rating rules. The Insurance Services Office maintains
the definition of long distance.
GENERAL INFORMATION
1. Is there a vehicle
maintenance program in
operation? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there a vehicle maintenance program in operation?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any vehicle maintenance program in operation.
GENERAL INFORMATION
2. Does the applicant obtain
MVR verifications on
drivers? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant obtain MVR verifications?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any applicant needing to obtain MVR verifications.
GENERAL INFORMATION
3. Does the applicant have a
driver recruiting method?
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have a specific driver recruiting method?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any applicant specific driver recruiting methods.
GENERAL INFORMATION
4. Are any drivers not
covered by Workers
Compensation? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any drivers not covered by workers compensation?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any drivers not covered by workers compensation.
GENERAL INFORMATION
5. Does applicant own or
operate equipment not
listed here? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant own or operate equipment not listed here?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant owns or operates equipment not listed on
the application.
ACORD 132 (2014/12) rev. 04-29-2014
Page 20 of 26
GENERAL INFORMATION
6. Does applicant haul any
dangerous, caustic,
radioactive or flammable
cargo? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant haul any dangerous, caustic, radioactive or flammable cargo?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant hauls any dangerous, caustic, radioactive
or flammable cargo.
GENERAL INFORMATION
7. Does applicant haul target
commodities? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant haul target commodities (i.e., stereos, televisions, pharmaceuticals, liquor,
meat, seafood, etc.).
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant hauls target commodities (ie.., stereos,
televisions, pharmaceuticals, liquor, meat, seafood, etc.)
GENERAL INFORMATION
8. Do drivers receive a
regular physical? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do drivers receive regular physicals?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether drivers receive regular physicals.
GENERAL INFORMATION
9. Does applicant hire
equipment from others?
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant hire equipment from others?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant hires equipment from others.
GENERAL INFORMATION
10. Does applicant rent or
lease vehicles or equipment
to others with/without
operators? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant rent or lease vehicles or equipment to others with or without operators?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant rents or leases vehicles or equipment to
others with or without operators.
GENERAL INFORMATION
11. Does applicant haul for
other truckers? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant haul for other truckers?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant hauls for other truckers.
GENERAL INFORMATION
12. Do other truckers
operate under the permit of
the applicant? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do other truckers operate under the permit of the applicant?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether other truckers operate under the permit of the
applicant.
GENERAL INFORMATION
13. Is coverage required for
travel in Canada or Mexico?
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is coverage required for travel in Canada or Mexico?.
ACORD 132 (2014/12) rev. 04-29-2014
Page 21 of 26
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether coverage is required for travel in Canada or Mexico.
GENERAL INFORMATION
14. Are drivers compensated
per trip? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are drivers compensated per trip?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether drivers are compensated per trip.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
GENERAL INFORMATION
15. Any Hold Harmless
agreements? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any hold harmless agreements?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any Hold Harmless Agreements.
GENERAL INFORMATION
16. Any drivers with
convictions for moving
traffic violations? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any drivers with convictions for moving traffic violations?.
GENERAL INFORMATION
Driver Number
Enter number: The producer's driver number for the driver involved in the accident or conviction.
GENERAL INFORMATION
Date
Enter date: The date of the accident or conviction. (MM/DD/YYYY)
GENERAL INFORMATION
Type
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is required.
GENERAL INFORMATION
Place
Enter text: The city of the accident or conviction.
GENERAL INFORMATION
Enter code: The state or province of the accident or conviction.
GENERAL INFORMATION
# Years Reviewed
Enter number: The number of years reviewed, in accordance with the company's and state's
requirements.
GENERAL INFORMATION
17. Do any vehicles have
special equipment mounted
or attached? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do any vehicles have special equipment mounted or attached?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any vehicles have special equipment mounted or
attached.
GENERAL INFORMATION
18. Does applicant pull
double or triple trailers?
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant pull double or triple trailers?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant pulls double or ripple trailers.
ACORD 132 (2014/12) rev. 04-29-2014
Page 22 of 26
GENERAL INFORMATION
19. Does applicant have tow
trucks or perform towing?
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant have tow trucks or perform towing?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has tow trucks or performs towing.
GENERAL INFORMATION
20. Are vehicles left
unlocked when unattended?
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are vehicles left unlocked and unattended?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether vehicles are left unlocked when unattended.
GENERAL INFORMATION
21. Are any overage,
shortage or damage claims
pending? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are overages, shortages and damage claims pending?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there are any overage, shortage or damage claims
pending.
GENERAL INFORMATION
22. Are all vehicles to be
included in this policy part
of a fleet?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are all vehicles to be included in this policy part of a fleet?.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
ACORD 45 Attached
Check the box (if applicable): Indicates that further additional interests appear on the attached
ACORD 45.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Additional Insured
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Employee as Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Other (Checkbox)
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Other (Blank Field)
Enter text: The description of the other type of additional interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Name and Address
Enter text: The additional interest's full name.
ACORD 132 (2014/12) rev. 04-29-2014
Page 23 of 26
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's country code.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Reference #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Certificate Required
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Interest in Item Number-
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Interest in Item Number -
Scheduled Item Number
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Interest in Item Number -
Other
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Item Description
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Additional Insured
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Employee as Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ACORD 132 (2014/12) rev. 04-29-2014
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ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Other (Checkbox)
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Other (Blank Field)
Enter text: The description of the other type of additional interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Name and Address
Enter text: The additional interest's full name.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's country code.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Reference #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Certificate Required
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Interest in Item Number-
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Interest in Item Number -
Scheduled Item Number
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Interest in Item Number -
Other
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTERESTS /
CERTIFICATE RECIPIENTS
Item Description
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ACORD 132 (2014/12) rev. 04-29-2014
Page 25 of 26
REMARKS
Remarks
Enter text: The remarks associated with the truckers 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 4
Section Name
Field Name
Description
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
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 Florida)
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. (MM/DD/YYYY)
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 132 (2014/12) rev. 04-29-2014
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