Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 137 MA (2012/02)
Massachusetts Commercial Auto,
Coverages / Limits Section
ACORD 137 MA, Massachusetts Commercial Auto Coverages /
Limits Section, is used to collect the coverage and limit information necessary to write
Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and
coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers / Motor
Carrier Section.
The following are the specific differences in this state.
* All coverages have been revised to reflect Massachusetts' unique requirements. Refer
to your state manual.
* The Fair Credit Reporting Act and fraud statements are revised to comply with
Massachusetts law and regulation.
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 month/day/year 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.
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
BUSINESS AUTO
Bodily Injury Liability - 1
Check the box (if applicable): Indicates that any auto is covered.
BUSINESS AUTO
2
Check the box (if applicable): Indicates that all owned autos are covered.
ACORD 137 MA (2012/02) rev. 02-29-2012
1 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO
9
Check the box (if applicable): Indicates that non-owned autos are covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
BI Each Person
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
BUSINESS AUTO
Limit
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
BUSINESS AUTO
BI Each Accident
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
BUSINESS AUTO
Compulsory Personal Injury
Protection - 5
Check the box (if applicable): Indicates that all owned autos which require no-fault
coverage are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
Per Person
Enter limit: The personal injury protection (PIP) per person limit amount.
BUSINESS AUTO
Ded
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
BUSINESS AUTO
Yourself
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured.
BUSINESS AUTO
Yourself and Family Members
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured and household members.
ACORD 137 MA (2012/02) rev. 02-29-2012
2 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
Compulsory: Damage to Someone
Else's Property - 1
Check the box (if applicable): Indicates that any auto is covered.
BUSINESS AUTO
2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO
9
Check the box (if applicable): Indicates that non-owned autos are covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
Each Accident
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
BUSINESS AUTO
Optional Medical Payments - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
Each Person
Enter limit: The medical payments per person limit.
BUSINESS AUTO
Compulsory Uninsured Motorists -
2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
ACORD 137 MA (2012/02) rev. 02-29-2012
3 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
6
Check the box (if applicable): Indicates that owned autos subject to compulsory uninsured
motorists law are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
BUSINESS AUTO
BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
BUSINESS AUTO
Limit
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit
varies by state. (in some states this may contain the combined single limit per accident
limit amount.)
BUSINESS AUTO
BI Each Accident
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may
contain the uninsured motorists combined single limit per accident limit). The use of this
limit varies by state.
BUSINESS AUTO
Property Damage
Enter limit: The uninsured motorists property damage per accident amount. The use of
this limit varies by state.
BUSINESS AUTO
Underinsured Motorists - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
6
Check the box (if applicable): Indicates that owned autos subject to compulsory uninsured
motorists law are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
ACORD 137 MA (2012/02) rev. 02-29-2012
4 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
BUSINESS AUTO
BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
BUSINESS AUTO
Limit
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
BUSINESS AUTO
BI Each Accident
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
BUSINESS AUTO
Optional Bodily injury to Others - 1
Check the box (if applicable): Indicates that any auto is covered.
BUSINESS AUTO
2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that owned autos subject to compulsory uninsured
motorists law are covered.
BUSINESS AUTO
8
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
9
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
BUSINESS AUTO
BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
BUSINESS AUTO
Limit
Enter limit: The optional bodily injury to others per person limit amount.
BUSINESS AUTO
BI Each Accident
Enter limit: The optional bodily injury to others per accident limit amount.
BUSINESS AUTO
Motorcycle Guest Occupant
Exclusion
Check the box (if applicable): Indicates guest occupant exclusion applies for motorcycles.
BUSINESS AUTO
Optional Hired / Borrowed Liability -
Yes
Check the box (if applicable): Indicates if hired / borrowed coverage applies.
ACORD 137 MA (2012/02) rev. 02-29-2012
5 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
States
Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO
Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO
Enter code: Indicates a state where autos are hired or borrowed.
BUSINESS AUTO
No
Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
BUSINESS AUTO
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
BUSINESS AUTO
If Any Basis
Check the box (if applicable): Indicates if the rating basis is if any. Check this box if the
exposure is minimal. The actual exposure is determined at the time of audit.
BUSINESS AUTO
Optional Non-Owned Liability - Yes
Check the box (if applicable): Indicates if non-owned coverage applies. As used here,
enter state(s) where employees use their own autos in the operations of the applicant's
business.
BUSINESS AUTO
States
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
Enter code: Indicates a state where autos are non-owned.
BUSINESS AUTO
No
Check the box (if applicable): Indicates that non-owned coverage does not apply.
BUSINESS AUTO
Group Type - Employees
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
employees.
BUSINESS AUTO
Number of Employees
Enter number: The number of employees that use their own automobiles.
BUSINESS AUTO
Volunteers
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
volunteers.
BUSINESS AUTO
Number of Volunteers
Enter number: The number of volunteers that use their own automobiles.
BUSINESS AUTO
Partners
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
partners.
BUSINESS AUTO
Number of Partners
Enter number: The number of partners that use their own automobiles.
BUSINESS AUTO
Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
BUSINESS AUTO
Additional Coverage Covered Auto
Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
ACORD 137 MA (2012/02) rev. 02-29-2012
6 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
BUSINESS AUTO
Additional Coverage Covered Auto
Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
BUSINESS AUTO
Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
BUSINESS AUTO
Additional Coverage Covered Auto
Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
BUSINESS AUTO
Optional Towing & Labor - 3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
Limit
Enter limit: The towing and labor limit amount.
BUSINESS AUTO
Optional Comprehensive - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
Optional Specified Causes of Loss -
2
Check the box (if applicable): Indicates that all owned autos are covered.
ACORD 137 MA (2012/02) rev. 02-29-2012
7 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
Optional Collision - 2
Check the box (if applicable): Indicates that all owned autos are covered.
BUSINESS AUTO
3
Check the box (if applicable): Indicates that owned private passenger autos are covered.
BUSINESS AUTO
4
Check the box (if applicable): Indicates that owned autos other than private passenger
autos are covered.
BUSINESS AUTO
7
Check the box (if applicable): Indicates that autos specified on the vehicle schedule are
covered.
BUSINESS AUTO
8
Check the box (if applicable): Indicates that hired autos are covered.
BUSINESS AUTO
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
BUSINESS AUTO
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage. Use the symbols specified for a coverage,
or enter a company-unique symbol if applicable.
BUSINESS AUTO
Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
BUSINESS AUTO
Additional Coverage Covered Auto
Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
BUSINESS AUTO
Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
BUSINESS AUTO
Additional Coverage Covered Auto
Symbols
Enter text: The symbols that apply to the other coverage listed.
BUSINESS AUTO
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
ACORD 137 MA (2012/02) rev. 02-29-2012
8 of 29
Section Name
Field Name
Field and/or Section Description
BUSINESS AUTO
Optional Hired Physical Damage -
States
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO
Enter code: Indicates a state where autos are hired and have physical damage coverage.
BUSINESS AUTO
# Days
Enter number: The number of days needed to rate Hired Physical Damage Coverage.
BUSINESS AUTO
# Veh
Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
BUSINESS AUTO
Coverage / Deductible - Comp
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
BUSINESS AUTO
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
BUSINESS AUTO
Spec C of L
Check the box (if applicable): Indicates the deductible is for specified causes of loss. The
Specified Cause of Loss Codes are:
SCL Specified Cause of Loss
F Fire
F&T Fire and Theft
F,T&W Fire, Theft and Wind
LSP Limited Specified Perils
SP Specified Perils
BUSINESS AUTO
Deductible
Enter deductible: The deductible associated with specified causes of loss coverage. As
used here, enter the deductible only if it is applicable to all vehicles.
BUSINESS AUTO
Coverage is: - Primary
Check the box (if applicable): Indicates if this coverage is on a primary basis.
BUSINESS AUTO
Secondary
Check the box (if applicable): Indicates if this coverage is on a secondary basis.
ENDORSEMENTS /
REMARKS
Endorsements / Remarks
Enter text: The remarks associated with the commercial vehicle line of business. Enter
any endorsements that apply. Be sure to include the form numbers and the required
information for attaching the endorsement. ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
ACORD 137 MA (2012/02) rev. 02-29-2012
9 of 29
Section Name
Field Name
Field and/or Section Description
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National
Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer
state license number.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
TRUCKERS
Bodily Injury Liability - 41
Check the box (if applicable): Indicates that any auto is covered.
TRUCKERS
42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS
50
Check the box (if applicable): Indicates that non-owned autos only are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
BI Each Person
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
TRUCKERS
Limit
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
TRUCKERS
BI Each Accident
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
TRUCKERS
Compulsory Personal Injury
Protection - 44
Check the box (if applicable): Indicates that owned autos subject to no-fault are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
ACORD 137 MA (2012/02) rev. 02-29-2012
10 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
Per Person
Enter limit: The personal injury protection (PIP) per person limit amount.
TRUCKERS
Ded
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
TRUCKERS
Yourself
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured.
TRUCKERS
Yourself and Family Members
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured and household members.
TRUCKERS
Compulsory: Damage to Someone
Else's Property - 41
Check the box (if applicable): Indicates that any auto is covered.
TRUCKERS
42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS
50
Check the box (if applicable): Indicates that non-owned autos only are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
Each Accident
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
TRUCKERS
Optional Medical Payments - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
45
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
Each Person
Enter limit: The medical payments per person limit.
ACORD 137 MA (2012/02) rev. 02-29-2012
11 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
Compulsory Uninsured Motorists -
42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
45
Check the box (if applicable): Indicates that owned autos subject to a compulsory
uninsured motorist law are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
TRUCKERS
BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
TRUCKERS
Limit
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit
varies by state. (in some states this may contain the combined single limit per accident
limit amount.)
TRUCKERS
BI Each Accident
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may
contain the uninsured motorists combined single limit per accident limit). The use of this
limit varies by state.
TRUCKERS
Property Damage
Enter limit: The uninsured motorists property damage per accident amount. The use of
this limit varies by state.
TRUCKERS
Underinsured Motorists - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
45
Check the box (if applicable): Indicates that owned autos subject to a compulsory
uninsured motorist law are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
ACORD 137 MA (2012/02) rev. 02-29-2012
12 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
TRUCKERS
BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
TRUCKERS
Limit
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
TRUCKERS
BI Each Accident
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
TRUCKERS
Optional Bodily injury to Others -
41
Check the box (if applicable): Indicates that any auto is covered.
TRUCKERS
42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS
50
Check the box (if applicable): Indicates that non-owned autos only are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
TRUCKERS
BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
TRUCKERS
Limit
Enter limit: The optional bodily injury to others per person limit amount.
TRUCKERS
BI Each Accident
Enter limit: The optional bodily injury to others per accident limit amount.
TRUCKERS
Motorcycle Guest Occupant
Exclusion
Check the box (if applicable): Indicates guest occupant exclusion applies for motorcycles.
TRUCKERS
Optional Non-Truckers Hired /
Borrowed Liability - Yes
Check the box (if applicable): Indicates if hired / borrowed coverage applies.
TRUCKERS
States
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS
Enter code: Indicates a state where autos are hired or borrowed.
ACORD 137 MA (2012/02) rev. 02-29-2012
13 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
No
Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
TRUCKERS
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
TRUCKERS
If Any Basis
Check the box (if applicable): Indicates if the rating basis is if any. Check this box if the
exposure is minimal. The actual exposure is determined at the time of audit.
TRUCKERS
Optional Truckers Hired /
Borrowed Liability - Yes
Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies.
TRUCKERS
States
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS
Enter code: Indicates a state where autos are hired or borrowed.
TRUCKERS
No
Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not
apply.
TRUCKERS
Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
TRUCKERS
If Any Basis
Check the box (if applicable): Indicates if the rating basis is if any.
TRUCKERS
Optional Non-Owned Liability - Yes
Check the box (if applicable): Indicates if non-owned coverage applies.
TRUCKERS
States
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
Enter code: Indicates a state where autos are non-owned.
TRUCKERS
No
Check the box (if applicable): Indicates that non-owned coverage does not apply.
TRUCKERS
Group Type - Employees
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
employees.
TRUCKERS
Number of Employees
Enter number: The number of employees that use their own automobiles.
TRUCKERS
Volunteers
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
volunteers.
TRUCKERS
Number of Volunteers
Enter number: The number of volunteers that use their own automobiles.
TRUCKERS
Partners
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
partners.
TRUCKERS
Number of Partners
Enter number: The number of partners that use their own automobiles.
ACORD 137 MA (2012/02) rev. 02-29-2012
14 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
TRUCKERS
Additional Coverage Covered Auto
Symbols
Enter text: The symbols that apply to the other coverage listed.
TRUCKERS
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
TRUCKERS
Optional Comprehensive - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
TRUCKERS
Optional Specified Causes of Loss -
42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
SCL
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
TRUCKERS
F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
TRUCKERS
FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this
vehicle.
TRUCKERS
FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of
loss on this vehicle.
ACORD 137 MA (2012/02) rev. 02-29-2012
15 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss
on this vehicle.
TRUCKERS
Deductible
Enter deductible: The deductible associated with specified causes of loss coverage.
TRUCKERS
Optional Collision - 42
Check the box (if applicable): Indicates that owned autos only are covered.
TRUCKERS
43
Check the box (if applicable): Indicates that owned commercial autos only are covered.
TRUCKERS
46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
47
Check the box (if applicable): Indicates that hired autos only are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
Deductible
Enter deductible: The collision deductible amount.
TRUCKERS
Optional Towing & Labor - 46
Check the box (if applicable): Indicates that specifically described autos are covered.
TRUCKERS
Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
TRUCKERS
Limit
Enter limit: The towing and labor limit amount.
TRUCKERS
Optional Comprehensive - 48
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
TRUCKERS
49
Check the box (if applicable): Indicates that your trailers in the possession of another
trucker under a trailer interchange agreement are covered.
TRUCKERS
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
TRUCKERS
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS
# Days
Enter number: The number of days during one year in which this exposure exists; that is,
the number of days in which the insured pulls trailers that are in his possession under a
Trailer Interchange Agreement.
TRUCKERS
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy,
are pulled by other tractors.
TRUCKERS
Optional Specified Causes of Loss -
48
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
ACORD 137 MA (2012/02) rev. 02-29-2012
16 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
49
Check the box (if applicable): Indicates that your trailers in the possession of another
trucker under a trailer interchange agreement are covered.
TRUCKERS
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
TRUCKERS
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS
# Days
Enter number: The number of days during one year in which this exposure exists; that is,
the number of days in which the insured pulls trailers that are in his possession under a
Trailer Interchange Agreement.
TRUCKERS
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy,
are pulled by other tractors.
TRUCKERS
Optional Collision - 48
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
TRUCKERS
49
Check the box (if applicable): Indicates that your trailers in the possession of another
trucker under a trailer interchange agreement are covered.
TRUCKERS
# Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
TRUCKERS
Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
TRUCKERS
# Days
Enter number: The number of days during one year in which this exposure exists; that is,
the number of days in which the insured pulls trailers that are in his possession under a
Trailer Interchange Agreement.
TRUCKERS
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy,
are pulled by other tractors.
TRUCKERS
Deductible
Enter deductible: The deductible amount applicable to trailer interchange collision
coverage.
TRUCKERS
Trailer Value
Enter amount: The trailer value as assigned by the trailer interchange agreement.
TRUCKERS
Optional Hired Physical Damage -
States
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS
Enter code: Indicates a state where autos are hired and have physical damage coverage.
ACORD 137 MA (2012/02) rev. 02-29-2012
17 of 29
Section Name
Field Name
Field and/or Section Description
TRUCKERS
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS
Enter code: Indicates a state where autos are hired and have physical damage coverage.
TRUCKERS
# Days
Enter number: The number of days needed to rate Hired Physical Damage Coverage.
TRUCKERS
# Veh
Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
TRUCKERS
Coverage is: - Primary
Check the box (if applicable): Indicates if this coverage is on a primary basis.
TRUCKERS
Secondary
Check the box (if applicable): Indicates if this coverage is on a secondary basis.
TRUCKERS
Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
TRUCKERS
Additional Coverage Covered Auto
Symbols
Enter text: The symbols that apply to the other coverage listed.
TRUCKERS
Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
ENDORSEMENTS /
REMARKS
Endorsements / Remarks
Enter text: The remarks associated with the commercial vehicle line of business. Enter
any endorsements that apply. Be sure to include the form numbers and the required
information for attaching the endorsement. ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National
Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer
state license number.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
MOTOR CARRIER SECTION Bodily Injury Liability - 61
Check the box (if applicable): Indicates that any auto is covered.
MOTOR CARRIER SECTION 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
ACORD 137 MA (2012/02) rev. 02-29-2012
18 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION 68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION 71
Check the box (if applicable): Indicates that non-owned autos only are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION BI Each Person
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
MOTOR CARRIER SECTION Limit
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
MOTOR CARRIER SECTION BI Each Accident
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
MOTOR CARRIER SECTION Protection - 65
Compulsory Personal Injury
Check the box (if applicable): Indicates that owned autos subject to no-fault are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION Per Person
Enter limit: The personal injury protection (PIP) per person limit amount.
MOTOR CARRIER SECTION Ded
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
MOTOR CARRIER SECTION Yourself
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured.
MOTOR CARRIER SECTION Yourself and Family Members
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured and household members.
ACORD 137 MA (2012/02) rev. 02-29-2012
19 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION Else's Property - 61
Compulsory: Damage to Someone
Check the box (if applicable): Indicates that any auto is covered.
MOTOR CARRIER SECTION 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION 68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION 71
Check the box (if applicable): Indicates that non-owned autos only are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION Each Accident
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
MOTOR CARRIER SECTION Optional Medical Payments - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION Each Person
Enter limit: The medical payments per person limit.
ACORD 137 MA (2012/02) rev. 02-29-2012
20 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION 62
Compulsory Uninsured Motorist -
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 66
Check the box (if applicable): Indicates that owned autos subject to a compulsory
uninsured motorist law are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
MOTOR CARRIER SECTION BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
MOTOR CARRIER SECTION Limit
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit
varies by state. (in some states this may contain the combined single limit per accident
limit amount.)
MOTOR CARRIER SECTION BI Each Accident
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may
contain the uninsured motorists combined single limit per accident limit). The use of this
limit varies by state.
MOTOR CARRIER SECTION Property Damage
Enter limit: The uninsured motorists property damage per accident amount. The use of
this limit varies by state.
MOTOR CARRIER SECTION Underinsured Motorists - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 66
Check the box (if applicable): Indicates that owned autos subject to a compulsory
uninsured motorist law are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
ACORD 137 MA (2012/02) rev. 02-29-2012
21 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
MOTOR CARRIER SECTION BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
MOTOR CARRIER SECTION Limit
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
MOTOR CARRIER SECTION BI Each Accident
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
MOTOR CARRIER SECTION 61
Optional Bodily injury to Others -
Check the box (if applicable): Indicates that any auto is covered.
MOTOR CARRIER SECTION 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION 68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION 71
Check the box (if applicable): Indicates that non-owned autos only are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION CSL
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the
coverage.
MOTOR CARRIER SECTION BI Ea Per
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person
limit on the coverage.
ACORD 137 MA (2012/02) rev. 02-29-2012
22 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION Limit
Enter limit: The optional bodily injury to others per person limit amount.
MOTOR CARRIER SECTION BI Each Accident
Enter limit: The optional bodily injury to others per accident limit amount.
MOTOR CARRIER SECTION Exclusion
Motorcycle Guest Occupant
Check the box (if applicable): Indicates guest occupant exclusion applies for motorcycles.
MOTOR CARRIER SECTION Borrowed Liability - Yes
Optional Non-Truckers Hired /
Check the box (if applicable): Indicates if hired / borrowed coverage applies.
MOTOR CARRIER SECTION States
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION No
Check the box (if applicable): Indicates that hired / borrowed coverage does not apply.
MOTOR CARRIER SECTION Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
MOTOR CARRIER SECTION If Any Basis
Check the box (if applicable): Indicates if the rating basis is if any. Check this box if the
exposure is minimal. The actual exposure is determined at the time of audit.
MOTOR CARRIER SECTION Borrowed Liability - Yes
Optional Truckers Hired /
Check the box (if applicable): Indicates if truckers hired / borrowed coverage applies.
MOTOR CARRIER SECTION States
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired or borrowed.
MOTOR CARRIER SECTION No
Check the box (if applicable): Indicates that truckers hired / borrowed coverage does not
apply.
MOTOR CARRIER SECTION Cost of Hire
Enter amount: The estimated amount it will cost to hire the vehicles.
MOTOR CARRIER SECTION If Any Basis
Check the box (if applicable): Indicates if the rating basis is if any.
MOTOR CARRIER SECTION - Yes
Optional Non-Owned Auto Liability
Check the box (if applicable): Indicates if non-owned coverage applies.
ACORD 137 MA (2012/02) rev. 02-29-2012
23 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION States
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are non-owned.
MOTOR CARRIER SECTION No
Check the box (if applicable): Indicates that non-owned coverage does not apply.
MOTOR CARRIER SECTION Group Type - Employees
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
employees.
MOTOR CARRIER SECTION Number of Employees
Enter number: The number of employees that use their own automobiles.
MOTOR CARRIER SECTION Volunteers
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
volunteers.
MOTOR CARRIER SECTION Number of Volunteers
Enter number: The number of volunteers that use their own automobiles.
MOTOR CARRIER SECTION Partners
Check the box (if applicable): Indicates that non-owned liability coverage pertains to
partners.
MOTOR CARRIER SECTION Number of Partners
Enter number: The number of partners that use their own automobiles.
MOTOR CARRIER SECTION Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
ACORD 137 MA (2012/02) rev. 02-29-2012
24 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION Symbols
Additional Coverage Covered Auto
Enter text: The symbols that apply to the other coverage listed.
MOTOR CARRIER SECTION Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
MOTOR CARRIER SECTION Optional Comprehensive - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION 68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
MOTOR CARRIER SECTION 62
Optional Specified Causes of Loss -
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION 68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION SCL
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
ACORD 137 MA (2012/02) rev. 02-29-2012
25 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
MOTOR CARRIER SECTION FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this
vehicle.
MOTOR CARRIER SECTION FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of
loss on this vehicle.
MOTOR CARRIER SECTION LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss
on this vehicle.
MOTOR CARRIER SECTION Deductible
Enter deductible: The deductible associated with specified causes of loss coverage.
MOTOR CARRIER SECTION Optional Collision - 62
Check the box (if applicable): Indicates that owned autos only are covered.
MOTOR CARRIER SECTION 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 64
Check the box (if applicable): Indicates that owned commercial autos only are covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION 68
Check the box (if applicable): Indicates that hired autos only are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION Deductible
Enter deductible: The collision deductible amount.
MOTOR CARRIER SECTION Optional Towing & Labor - 63
Check the box (if applicable): Indicates that owned private passenger autos only are
covered.
MOTOR CARRIER SECTION 67
Check the box (if applicable): Indicates that specifically described autos are covered.
MOTOR CARRIER SECTION Other Covered Auto Symbol
Check the box (if applicable): Indicates that a symbol other than those listed should be
used.
MOTOR CARRIER SECTION Description
Other Covered Auto Symbol
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION Limit
Enter limit: The towing and labor limit amount.
ACORD 137 MA (2012/02) rev. 02-29-2012
26 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
MOTOR CARRIER SECTION Symbols
Additional Coverage Covered Auto
Enter text: The symbols that apply to the other coverage listed.
MOTOR CARRIER SECTION Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
MOTOR CARRIER SECTION Other Deductible
Enter deductible: The deductible amount of the coverage.
MOTOR CARRIER SECTION Optional Comprehensive - 69
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
MOTOR CARRIER SECTION 70
Check the box (if applicable): Indicates that your trailers in the possession of another
trucker under a trailer interchange agreement are covered.
MOTOR CARRIER SECTION # Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
MOTOR CARRIER SECTION Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER SECTION # Days
Enter number: The number of days during one year in which this exposure exists; that is,
the number of days in which the insured pulls trailers that are in his possession under a
Trailer Interchange Agreement.
MOTOR CARRIER SECTION Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy,
are pulled by other tractors.
MOTOR CARRIER SECTION 69
Optional Specified Causes of Loss -
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
MOTOR CARRIER SECTION 70
Check the box (if applicable): Indicates that your trailers in the possession of another
trucker under a trailer interchange agreement are covered.
MOTOR CARRIER SECTION # Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
MOTOR CARRIER SECTION Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER SECTION # Days
Enter number: The number of days during one year in which this exposure exists; that is,
the number of days in which the insured pulls trailers that are in his possession under a
Trailer Interchange Agreement.
MOTOR CARRIER SECTION Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy,
are pulled by other tractors.
ACORD 137 MA (2012/02) rev. 02-29-2012
27 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION Optional Collision - 69
Check the box (if applicable): Indicates that trailers in your possession under a trailer
interchange agreement are covered.
MOTOR CARRIER SECTION 70
Check the box (if applicable): Indicates that your trailers in the possession of another
trucker under a trailer interchange agreement are covered.
MOTOR CARRIER SECTION # Trailers
Enter number: The number of trailers operated by the insured under a Trailer Interchange
Agreement.
MOTOR CARRIER SECTION Farth Zone
Enter code: The state of the farthest zone where trailer interchange coverage applies.
MOTOR CARRIER SECTION # Days
Enter number: The number of days during one year in which this exposure exists; that is,
the number of days in which the insured pulls trailers that are in his possession under a
Trailer Interchange Agreement.
MOTOR CARRIER SECTION Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy,
are pulled by other tractors.
MOTOR CARRIER SECTION Deductible
Enter deductible: The deductible amount applicable to trailer interchange collision
coverage.
MOTOR CARRIER SECTION Trailer Value
Enter amount: The trailer value as assigned by the trailer interchange agreement.
MOTOR CARRIER SECTION States
Optional Hired Physical Damage -
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION
Enter code: Indicates a state where autos are hired and have physical damage coverage.
MOTOR CARRIER SECTION # Days
Enter number: The number of days needed to rate Hired Physical Damage Coverage.
MOTOR CARRIER SECTION # Veh
Enter number: The number of vehicles needed to rate Hired Physical Damage Coverage.
MOTOR CARRIER SECTION Coverage is: - Primary
Check the box (if applicable): Indicates if this coverage is on a primary basis.
ACORD 137 MA (2012/02) rev. 02-29-2012
28 of 29
Section Name
Field Name
Field and/or Section Description
MOTOR CARRIER SECTION Secondary
Check the box (if applicable): Indicates if this coverage is on a secondary basis.
MOTOR CARRIER SECTION Additional Coverage Description
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
MOTOR CARRIER SECTION Symbols
Additional Coverage Covered Auto
Enter text: The symbols that apply to the other coverage listed.
MOTOR CARRIER SECTION Additional Coverage Limit
Enter limit: The limit amount of the other coverage.
ENDORSEMENTS /
REMARKS
Endorsements / Remarks
Enter text: The remarks associated with the commercial vehicle line of business. Enter
any endorsements that apply. Be sure to include the form numbers and the required
information for attaching the endorsement. ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National
Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer
state license number.
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
ACORD 137 MA (2012/02) rev. 02-29-2012
29 of 29