ACORD 137 MN (2014/12) - MINNESOTA COMMERCIAL AUTO COVERAGES / LIMITS SECTION

ACORD 137 MN (2014/12) - MINNESOTA COMMERCIAL AUTO COVERAGES / LIMITS SECTION
ACORD 137 MN, Minnesota 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.
Use this form with ACORD 127, Business Auto Section, and/or ACORD 132, Truckers / Motor Carriers Section.
The following are the specific differences in this state:
* Personal Injury Protection items revised to reflect Minnesota's unique coverages.
* A statement is added requiring the applicant to acknowledge receipt of a copy of the Minnesota Guaranty Association Notice, ACORD 65 MN.
* A statement is added acknowledging the offer of stacked Personal Injury Protection coverage if more than one vehicle is owned.
* A statement is added acknowledging the offer of Uninsured / Underinsured Motorists coverage up to the limits of Bodily Injury Liability coverage.
* A statement is added acknowledging the offer of Work Loss Exclusion under Personal Injury Protection coverage.
* A statement is added referencing the company's right to cancel coverage during the fifty-nine (59) days following the issuance of coverage, for
any reason not prohibited by law.
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.
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 1 of 24
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
BUSINESS AUTO
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.
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
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 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
Property Damage
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
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
Limit
Enter limit: The personal injury protection (PIP) limit amount.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 2 of 24
BUSINESS AUTO
Non-Stckd
Check the box (if applicable): Indicates the personal injury protection (PIP) is not stacked.
BUSINESS AUTO
Combined PIP
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage is
stacked/combined.
BUSINESS AUTO
$100 Med Exp Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $100 medical
expense deductible.
BUSINESS AUTO
$100 Med Exp Ded & $200
Wk Loss Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $100 medical
expense deductible and a $200 work loss deductible.
BUSINESS AUTO
$200 Wk Loss Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $200 work loss
deductible.
BUSINESS AUTO
No Deductible
Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible
that applies.
BUSINESS AUTO
Work Loss Excl Named Ins
Only, Age 65 or Older, or
Age 60 - 64 and Retired and
Receiving a Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured only age 65 or older or age 60 - 64 and retired and receiving a
pension.
BUSINESS AUTO
Work Loss Excl Named Ins
& Any Family Member, Age
65 or Older, or Age 60 - 64
and Retired and Receiving a
Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured and family members age 65 or older or age 60 - 64 and retired
and receiving a pension.
BUSINESS AUTO
Work Loss Excl Any Family
Member, Age 65 or Older, or
Age 60 - 64 and Retired and
Receiving a Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to any family member age 65 or older or age 60 - 64 and retired and receiving a
pension.
BUSINESS AUTO
Additional P.I.P - 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
Work Loss
Enter limit: The additional personal injury protection (APIP) work/wage loss limit amount.
BUSINESS AUTO
Add'l Med Exp
Enter limit: The additional personal injury protection (APIP) additional medical expense limit
amount.
BUSINESS AUTO
Medical Payments - 2
Check the box (if applicable): Indicates that all owned autos are covered.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 3 of 24
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
Uninsured / 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.
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 / underinsured motorists bodily injury per person limit. The use of this
limit varies by state. On commercial policies, this may contain the combined single limit per
accident amount.
BUSINESS AUTO
BI Each Accident
Enter limit: The uninsured / underinsured motorists bodily injury per accident limit (in some
states this may contain the uninsured / underinsured motorists combined single limit per
accident limit). The use of this limit varies by state.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 4 of 24
BUSINESS AUTO
Hired / Borrowed Liability -
Yes
Check the box (if applicable): Indicates if hired / borrowed coverage applies.
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
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 5 of 24
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
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
COMP / OTC - 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
Anti-Theft Discount Applies
Y / N
Enter Y for a Yes response. Input N for No response. Indicates if an anti-theft discount
applies.
BUSINESS AUTO
Specified Causes of Loss - 2
Check the box (if applicable): Indicates that all owned autos are covered.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 6 of 24
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
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 MN (2014/12) rev. 03-28-2014
Page 7 of 24
BUSINESS AUTO
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
Coll
Check the box (if applicable): Indicates the vehicle has collision coverage.
BUSINESS AUTO
Deductible
Enter deductible: The collision deductible amount.
BUSINESS AUTO
Safety Glass
Check the box (if applicable): Indicates the deductible is for safety glass coverage.
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.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 8 of 24
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.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
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).
TRUCKERS
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
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 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
Property Damage
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
Personal Injury Protection -
44
Check the box (if applicable): Indicates that owned autos subject to no-fault are covered.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 9 of 24
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
Limit
Enter limit: The personal injury protection (PIP) limit amount.
TRUCKERS
Non-Stckd
Check the box (if applicable): Indicates the personal injury protection (PIP) is not stacked.
TRUCKERS
Combined PIP
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage is
stacked/combined.
TRUCKERS
$100 Med Exp Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $100 medical
expense deductible.
TRUCKERS
$100 Med Exp Ded & $200
Wk Loss Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $100 medical
expense deductible and a $200 work loss deductible.
TRUCKERS
$200 Wk Loss Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $200 work loss
deductible.
TRUCKERS
No Deductible
Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible
that applies.
TRUCKERS
Work Loss Excl Named Ins
Only, Age 65 or Older, or
Age 60 - 64 and Retired and
Receiving a Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured only age 65 or older or age 60 - 64 and retired and receiving a
pension.
TRUCKERS
Work Loss Excl Named Ins
& Any Family Member, Age
65 or Older, or Age 60 - 64
and Retired and Receiving a
Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured and family members age 65 or older or age 60 - 64 and retired
and receiving a pension.
TRUCKERS
Work Loss Excl Any Family
Member, Age 65 or Older, or
Age 60 - 64 and Retired and
Receiving a Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to any family member age 65 or older or age 60 - 64 and retired and receiving a
pension.
TRUCKERS
Additional P.I.P - 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.
TRUCKERS
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 10 of 24
TRUCKERS
Work Loss
Enter limit: The additional personal injury protection (APIP) work/wage loss limit amount.
TRUCKERS
Add'l Med Exp
Enter limit: The additional personal injury protection (APIP) additional medical expense limit
amount.
TRUCKERS
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
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
Each Person
Enter limit: The medical payments per person limit.
TRUCKERS
Uninsured / 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.
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
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 11 of 24
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 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
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. Check this box if the
exposure is minimal. The actual exposure is determined at the time of audit.
TRUCKERS
Non-Owned Auto 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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 12 of 24
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.
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
COMP / OTC - 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
Anti-Theft Discount Applies
Y / N
Enter Y for a Yes response. Input N for No response. Indicates if an anti-theft discount
applies.
TRUCKERS
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
TRUCKERS
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 13 of 24
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.
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
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
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
COMP / OTC - 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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 14 of 24
TRUCKERS
Radius
Enter number: The radius in actual mileage within which trailers, covered by this policy, are
pulled by other tractors.
TRUCKERS
Specified Causes of Loss -
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
Collision
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
Anti-Theft Discount Applies
Y / N
Enter Y for a Yes response. Input N for No response. Indicates if an anti-theft discount
applies for trailer interchange.
TRUCKERS
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 15 of 24
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.
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.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
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).
MOTOR CARRIER SECTION
Liability - 61
Check the box (if applicable): Indicates that any auto is covered.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 16 of 24
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
Other Covered Auto Symbol
Description
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 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
Property Damage
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
Personal Injury Protection -
65
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
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Limit
Enter limit: The personal injury protection (PIP) limit amount.
MOTOR CARRIER SECTION
Non-Stckd
Check the box (if applicable): Indicates the personal injury protection (PIP) is not stacked.
MOTOR CARRIER SECTION
Combined PIP
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage is
stacked/combined.
MOTOR CARRIER SECTION
$100 Med Exp Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $100 medical
expense deductible.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 17 of 24
MOTOR CARRIER SECTION
$100 Med Exp Ded & $200
Wk Loss Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $100 medical
expense deductible and a $200 work loss deductible.
MOTOR CARRIER SECTION
$200 Wk Loss Ded
Check the box (if applicable): Indicates the personal injury protection (PIP) has a $200 work loss
deductible.
MOTOR CARRIER SECTION
No Deductible
Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible
that applies.
MOTOR CARRIER SECTION
Work Loss Excl Named Ins
Only, Age 65 or Older, or
Age 60 - 64 and Retired and
Receiving a Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured only age 65 or older or age 60 - 64 and retired and receiving a
pension.
MOTOR CARRIER SECTION
Work Loss Excl Named Ins
& Any Family Member, Age
65 or Older, or Age 60 - 64
and Retired and Receiving a
Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured and family members age 65 or older or age 60 - 64 and retired
and receiving a pension.
MOTOR CARRIER SECTION
Work Loss Excl Any Family
Member, Age 65 or Older, or
Age 60 - 64 and Retired and
Receiving a Pension
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to any family member age 65 or older or age 60 - 64 and retired and receiving a
pension.
MOTOR CARRIER SECTION
Additional P.I.P - 65
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
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Work Loss
Enter limit: The additional personal injury protection (APIP) work/wage loss limit amount.
MOTOR CARRIER SECTION
Add'l Med Exp
Enter limit: The additional personal injury protection (APIP) additional medical expense limit
amount.
MOTOR CARRIER SECTION
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 18 of 24
MOTOR CARRIER SECTION
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Each Person
Enter limit: The medical payments per person limit.
MOTOR CARRIER SECTION
Uninsured / 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.
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
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 / underinsured motorists bodily injury per person limit. The use of this
limit varies by state. On commercial policies, this may contain the combined single limit per
accident amount.
MOTOR CARRIER SECTION
BI Each Accident
Enter limit: The uninsured / underinsured motorists bodily injury per accident limit (in some
states this may contain the uninsured / underinsured motorists combined single limit per
accident limit). The use of this limit varies by state.
MOTOR CARRIER SECTION
Non-Truckers Hired /
Borrowed Liability - Yes
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 19 of 24
MOTOR CARRIER SECTION
Truckers Hired / Borrowed
Liability - Yes
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. Check this box if the
exposure is minimal. The actual exposure is determined at the time of audit.
MOTOR CARRIER SECTION
Non-Owned Auto Liability -
Yes
Check the box (if applicable): Indicates if non-owned coverage applies.
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 20 of 24
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
Additional Coverage
Covered Auto Symbols
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
COMP / OTC - 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
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Anti-Theft Discount Applies
Y / N
Enter Y for a Yes response. Input N for No response. Indicates if an anti-theft discount
applies.
MOTOR CARRIER SECTION
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
MOTOR CARRIER SECTION
Specified Causes of Loss -
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
Other Covered Auto Symbol
Description
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.
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
Page 21 of 24
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
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
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Deductible
Enter deductible: The collision deductible amount.
MOTOR CARRIER SECTION
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
Other Covered Auto Symbol
Description
Enter code: The symbol code for the coverage.
MOTOR CARRIER SECTION
Limit
Enter limit: The towing and labor limit amount.
MOTOR CARRIER SECTION
COMP / OTC - 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.
ACORD 137 MN (2014/12) rev. 03-28-2014
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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
Specified Causes of Loss -
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
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
Anti-Theft Discount Applies
Y / N
Enter Y for a Yes response. Input N for No response. Indicates if an anti-theft discount
applies for trailer interchange.
MOTOR CARRIER SECTION
Hired Physical Damage -
States
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.
ACORD 137 MN (2014/12) rev. 03-28-2014
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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.
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
Additional Coverage
Covered Auto Symbols
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.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 137 MN (2014/12) rev. 03-28-2014
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