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ACORD 138 HI (2005/01) 1 of 9
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 10/30/2008. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 138 HI (2005/01) |
Hawaii Garage and Dealers, Coverages/Limits Section |
The title of the form. The ACORD 138 HI - Hawaii Garage and Dealers Coverages/Limits Section is used to collect the coverage and limit information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The following are the specific differences in this state. * Unique Personal Injury Protection and Additional Personal Injury Protection items are provided. * The applicant can select "stacked" or "non-stacked" Uninsured and Underinsured Motorists BI coverage; however, there is no UM or UIM PD coverage available. * A state-specific fraud warning is included on the back of the form. |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
Applicant (First Named Insured) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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COVERAGES/LIMITS |
Liability 21 |
Check the box (if applicable): Indicates any auto is covered. As used here, Garage or Dealers policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used, symbols 21 through 26 provide fleet automatic coverage. symbol 21 includes Hired and Non-Owned auto coverage. if symbol 21 is not used and Hired Auto (symbol 28) or Non-Owned Auto (symbol 29) coverage is desired, those symbols must be checked. The symbols indicate the automobiles to which each coverage applies. The symbol ""triggers"" the coverage. For exact policy definitions of the symbols, please refer to the company's policy declarations page. |
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COVERAGES/LIMITS |
Liability 22 |
Check the box (if applicable): Indicates all owned autos are covered. |
ACORD 138 HI (2005/01) 2 of 9
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Section Name |
Field Name |
Field and/or Section Description |
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COVERAGES/LIMITS |
Liability 23 |
Check the box (if applicable): Indicates only owned private passengers autos are covered. |
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COVERAGES/LIMITS |
Liability 24 |
Check the box (if applicable): Indicates owned autos other than private passenger autos are covered. |
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COVERAGES/LIMITS |
Liability 27 |
Check the box (if applicable): Indicates specifically described autos are covered. |
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COVERAGES/LIMITS |
Liability 28 |
Check the box (if applicable): Indicates only hired autos are covered. |
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COVERAGES/LIMITS |
Liability 29 |
Check the box (if applicable): Indicates non-owned autos used in garage business are covered. |
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COVERAGES/LIMITS |
EA Accident Auto Only ($) |
Enter limit: The liability each accident limit for garage operations auto only. For Dealers, use this field to enter the Policy Combined Single Limit. |
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COVERAGES/LIMITS |
Other Than Auto Only ($) |
Enter limit: The liability each accident limit for garage operations other than auto only. |
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COVERAGES/LIMITS |
Aggregate ($) |
Enter limit: The liability aggregate limit for garage operations other than auto only. |
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COVERAGES/LIMITS |
Dealers Only-Limited |
Check the box (if applicable): Indicates the liability coverage is limited for dealers. |
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COVERAGES/LIMITS |
Dealers Only-Unlimited |
Check the box (if applicable): Indicates the liability coverage is unlimited for dealers. |
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COVERAGES/LIMITS |
Personal Injury Protection 25 |
Check the box (if applicable): Indicates owned autos subject to no-fault are covered. |
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COVERAGES/LIMITS |
Personal Injury Protection 27 |
Check the box (if applicable): Indicates specifically described autos are covered. |
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COVERAGES/LIMITS |
Personal Injury Protection $10,000 Ded ($) |
Enter deductible: The deductible amount for personal injury protection (PIP) coverage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
$10000 Co Pay Option (checkbox) |
Check the box (if applicable): Indicates the personal injury protection (PIP) co pay option has been selected. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Co Pay % |
Enter percentage: The personal injury protection (PIP) co pay percentage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Managed Care Option (checkbox) |
Check the box (if applicable): Indicates personal injury protection (PIP) managed care coverage has been selected. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Co Pay Option (checkbox) |
Check the box (if applicable): Indicates work/wage loss coverage has been selected as part of additional personal injury protection (APIP) coverage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Co Pay Option % |
Enter percentage: The personal injury protection (PIP) managed care co pay percentage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Ded ($) |
Enter deductible: The personal injury protection (PIP) managed care deductible amount. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Additional P.I.P. 25 |
Check the box (if applicable): Indicates owned autos subject to no-fault are covered. |
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COVERAGES/LIMITS |
Additional P.I.P. 27 |
Check the box (if applicable): Indicates specifically described autos are covered. |
ACORD 138 HI (2005/01) 3 of 9
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Section Name |
Field Name |
Field and/or Section Description |
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COVERAGES/LIMITS |
Add'l Med Exp (checkbox) |
Check the box (if applicable): Indicates additional medical expense coverage has been selected as part of additional personal injury protection (APIP) coverage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Add'l Med Exp ($) |
Enter limit: The additional personal injury protection (APIP) additional medical expense limit amount. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Wage Loss ($) |
Enter limit: The additional personal injury protection (APIP) work/wage loss limit amount. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Dth Ben (checkbox) |
Check the box (if applicable): Indicates accidental death benefit has been selected as part of additional personal injury protection (APIP) coverage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Dth Ben ($) |
Enter limit: The additional personal injury protection (APIP) accidental death benefit limit amount. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Fun Exp (checkbox) |
Check the box (if applicable): Indicates funeral expense benefit has been selected as part of additional personal injury protection (APIP) coverage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Fun Exp ($) |
Enter limit: The limit amount for funeral expense benefit coverage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Alt Exp (checkbox) |
Check the box (if applicable): Indicates the alternate expense option has been selected on the additional personal injury protection (APIP) coverage. As used here, refer to applicable State Manual for options. |
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COVERAGES/LIMITS |
Medical Payments 21 (checkbox) |
Check the box (if applicable): Indicates any auto is covered. |
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COVERAGES/LIMITS |
Medical Payments 22 (checkbox) |
Check the box (if applicable): Indicates all owned autos are covered. |
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COVERAGES/LIMITS |
Medical Payments 23 (checkbox) |
Check the box (if applicable): Indicates only owned private passengers autos are covered. |
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COVERAGES/LIMITS |
Medical Payments 24 (checkbox) |
Check the box (if applicable): Indicates owned autos other than private passenger autos are covered. |
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COVERAGES/LIMITS |
Medical Payments 27 (checkbox) |
Check the box (if applicable): Indicates specifically described autos are covered. |
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COVERAGES/LIMITS |
Medical Payments 28 (checkbox) |
Check the box (if applicable): Indicates only hired autos are covered. |
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COVERAGES/LIMITS |
Medical Payments 29 (checkbox) |
Check the box (if applicable): Indicates non-owned autos used in garage business are covered. |
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COVERAGES/LIMITS |
Limit ($) |
Enter limit: The medical payments per person limit. |
ACORD 138 HI (2005/01) 4 of 9
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Section Name |
Field Name |
Field and/or Section Description |
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COVERAGES/LIMITS |
Automobile (checkbox) |
Check the box (if applicable): Indicates the medical payments coverage is for automobile. |
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COVERAGES/LIMITS |
Prem Operations (checkbox) |
Check the box (if applicable): Indicates the medical payments coverage is for premises operations. |
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COVERAGES/LIMITS |
Uninsured Motorists Stacked (checkbox) |
Check the box (if applicable): Indicates the uninsured motorists coverage is stacked. |
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COVERAGES/LIMITS |
Non-Stkd (checkbox) |
Check the box (if applicable): Indicates the uninsured motorists coverage is not stacked. |
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COVERAGES/LIMITS |
Uninsured Motorists 22 |
Check the box (if applicable): Indicates all owned autos are covered. |
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COVERAGES/LIMITS |
Uninsured Motorists 23 |
Check the box (if applicable): Indicates only owned private passengers autos are covered. |
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COVERAGES/LIMITS |
Uninsured Motorists 24 |
Check the box (if applicable): Indicates owned autos other than private passenger autos are covered. |
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COVERAGES/LIMITS |
Uninsured Motorists 26 |
Check the box (if applicable): Indicates owned autos subject to uninsured motorists law are covered. |
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COVERAGES/LIMITS |
Uninsured Motorists 27 |
Check the box (if applicable): Indicates specifically described autos are covered. |
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COVERAGES/LIMITS |
CSL (checkbox) |
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
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COVERAGES/LIMITS |
BI Ea Per (checkbox) |
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage. |
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COVERAGES/LIMITS |
BI Ea Per ($) |
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.) |
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COVERAGES/LIMITS |
BI Each Accident ($) |
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state. |
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COVERAGES/LIMITS |
Underinsured Motorists Stacked (checkbox) |
Check the box (if applicable): Indicates the underinsured motorists coverage is stacked. |
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COVERAGES/LIMITS |
Non-Stkd (checkbox) |
Check the box (if applicable): Indicates the underinsured motorists coverage is not stacked. |
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COVERAGES/LIMITS |
Underinsured Motorists 22 |
Check the box (if applicable): Indicates all owned autos are covered. |
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COVERAGES/LIMITS |
Underinsured Motorists 23 |
Check the box (if applicable): Indicates only owned private passengers autos are covered. |
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COVERAGES/LIMITS |
Underinsured Motorists 24 |
Check the box (if applicable): Indicates owned autos other than private passenger autos are covered. |
ACORD 138 HI (2005/01) 5 of 9
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Section Name |
Field Name |
Field and/or Section Description |
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COVERAGES/LIMITS |
Underinsured Motorists 26 |
Check the box (if applicable): Indicates owned autos subject to uninsured motorists law are covered. |
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COVERAGES/LIMITS |
Underinsured Motorists 27 |
Check the box (if applicable): Indicates specifically described autos are covered. |
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COVERAGES/LIMITS |
CSL (Checkbox) |
Check the box (if applicable): Indicates if the limit shown is for combined single limit on the coverage. |
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COVERAGES/LIMITS |
BI Ea Per (checkbox) |
Check the box (if applicable): Indicates if the limit shown is the bodily injury each person limit on the coverage. |
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COVERAGES/LIMITS |
BI Ea Per ($) |
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount |
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COVERAGES/LIMITS |
BI Each Accident ($) |
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state. |
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PHYSICAL DAMAGE |
Comp / OTC (checkbox) |
Check the box (if applicable): Indicates the physical damage is comprehensive/other than collision. |
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PHYSICAL DAMAGE |
Specified Perils (checkbox) |
Check the box (if applicable): Indicates the physical damage coverage is for specified perils. |
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PHYSICAL DAMAGE |
Specified Perils Other |
Enter text: The codes associated with specified perils coverage. The codes are: F - Fire, F&T - Fire and Theft, FTW - Fire, Theft and Wind, LSP - Limited Specified Perils, SP -Specified Perils. |
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PHYSICAL DAMAGE |
Specified Perils 22 |
Check the box (if applicable): Indicates all owned autos are covered. |
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PHYSICAL DAMAGE |
Specified Perils 23 |
Check the box (if applicable): Indicates only owned private passengers autos are covered. |
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PHYSICAL DAMAGE |
Specified Perils 24 |
Check the box (if applicable): Indicates owned autos other than private passenger autos are covered. |
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PHYSICAL DAMAGE |
Specified Perils 27 |
Check the box (if applicable): Indicates specifically described autos are covered. |
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PHYSICAL DAMAGE |
Specified Perils 28 |
Check the box (if applicable): Indicates only hired autos are covered. |
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PHYSICAL DAMAGE |
Specified Perils 31 |
Check the box (if applicable): Indicates autos on consignment and dealer autos are covered. |
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PHYSICAL DAMAGE |
LOC # One |
Enter number: The producer assigned number for the location. |
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PHYSICAL DAMAGE |
Enter the Limits for Each Location One |
Enter limit: The physical damage comprehensive/other than collision or specified perils limit amount. |
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PHYSICAL DAMAGE |
Deductible Per Auto One |
Enter deductible: The physical damage comprehensive/other than collision or specified perils per auto deductible amount. |
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PHYSICAL DAMAGE |
Maximum Deductible Per Loss One |
Enter deductible: The physical damage comprehensive/other than collision or specified perils maximum deductible per loss amount. |
ACORD 138 HI (2005/01) 6 of 9
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Section Name |
Field Name |
Field and/or Section Description |
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PHYSICAL DAMAGE |
LOC # Two |
Enter number: The producer assigned number for the location. |
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PHYSICAL DAMAGE |
Enter the Limits for Each Location Two |
Enter limit: The physical damage comprehensive/other than collision or specified perils limit amount. |
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PHYSICAL DAMAGE |
Deductible Per Auto Two |
Enter deductible: The physical damage comprehensive/other than collision or specified perils per auto deductible amount. |
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PHYSICAL DAMAGE |
Maximum Deductible Per Loss Two |
Enter deductible: The physical damage comprehensive/other than collision or specified perils maximum deductible per loss amount. |
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PHYSICAL DAMAGE |
LOC # Three |
Enter number: The producer assigned number for the location. |
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PHYSICAL DAMAGE |
Enter the Limits for Each Location Three |
Enter limit: The physical damage comprehensive/other than collision or specified perils limit amount. |
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PHYSICAL DAMAGE |
Deductible Per Auto Three |
Enter deductible: The physical damage comprehensive/other than collision or specified perils per auto deductible amount. |
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PHYSICAL DAMAGE |
Maximum Deductible Per Loss Three |
Enter deductible: The physical damage comprehensive/other than collision or specified perils maximum deductible per loss amount. |
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PHYSICAL DAMAGE |
Collision 22 |
Check the box (if applicable): Indicates all owned autos are covered. |
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PHYSICAL DAMAGE |
Collision 23 |
Check the box (if applicable): Indicates only owned private passengers autos are covered. |
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PHYSICAL DAMAGE |
Collision 24 |
Check the box (if applicable): Indicates owned autos other than private passenger autos are covered. |
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PHYSICAL DAMAGE |
Collision 27 |
Check the box (if applicable): Indicates specifically described autos are covered. |
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PHYSICAL DAMAGE |
Collision 28 |
Check the box (if applicable): Indicates only hired autos are covered. |
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PHYSICAL DAMAGE |
Collision 31 |
Check the box (if applicable): Indicates autos on consignment and dealer autos are covered. |
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PHYSICAL DAMAGE |
Collision Deductible ($) |
Enter deductible: The physical damage collision deductible amount. |
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PHYSICAL DAMAGE |
Additional Coverage Description |
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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PHYSICAL DAMAGE |
Additional Coverage Covered Auto Symbols |
Enter text: The symbols that apply to the other coverage listed. |
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PHYSICAL DAMAGE |
Additional Coverage Limit |
Enter limit: The limit amount of the other coverage. |
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GARAGE KEEPERS |
Legal Liability (checkbox) |
Check the box (if applicable): Indicates the policy is to be written on a legal liability basis. |
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GARAGE KEEPERS |
Direct Basis (checkbox) |
Check the box (if applicable): Indicates the policy is to be written on a direct basis. |
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GARAGE KEEPERS |
Primary (checkbox) |
Check the box (if applicable): Indicates this policy is the primary coverage. |
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GARAGE KEEPERS |
Excess (checkbox) |
Check the box (if applicable): Indicates this policy is for excess coverage. |
ACORD 138 HI (2005/01) 7 of 9
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Section Name |
Field Name |
Field and/or Section Description |
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GARAGE KEEPERS |
Comp / OTC (checkbox) |
Check the box (if applicable): Indicates the garage keepers coverage is comprehensive/other than collision. |
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GARAGE KEEPERS |
Specified Perils (checkbox) |
Check the box (if applicable): Indicates the garage keepers coverage is for specified perils. |
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GARAGE KEEPERS |
Specified Perils Other |
Enter text: The codes associated with specified perils coverage. The codes are: F - Fire, F&T - Fire and Theft, FTW - Fire, Theft and Wind, LSP - Limited Specified Perils, SP -Specified Perils. |
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GARAGE KEEPERS |
30 (Checkbox) |
Check the box (if applicable): Indicates autos left for service, repairs and/or storage are covered. |
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GARAGE KEEPERS |
LOC # One |
Enter number: The producer assigned number for the location. 'The location number for the physical damage coverages should correspond to a location number documented on the ACORD 125. |
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GARAGE KEEPERS |
Enter the Limits for Each Location One |
Enter limit: The garage keepers comprehensive/other than collision or specified perils limit amount. |
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GARAGE KEEPERS |
# of Autos One |
Enter number: The number of vehicles located on the premises. |
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GARAGE KEEPERS |
Deductible Per Auto One |
Enter deductible: The garage keepers comprehensive/other than collision or specified perils per auto deductible amount. |
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GARAGE KEEPERS |
Maximum Deductible Per Loss One |
Enter deductible: The garage keepers comprehensive/other than collision or specified perils maximum deductible per loss amount. |
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GARAGE KEEPERS |
LOC # Two |
Enter number: The producer assigned number for the location. 'The location number for the physical damage coverages should correspond to a location number documented on the ACORD 125. |
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GARAGE KEEPERS |
Enter the Limits for Each Location Two |
Enter limit: The garage keepers comprehensive/other than collision or specified perils limit amount. |
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GARAGE KEEPERS |
# of Autos Two |
Enter number: The number of vehicles located on the premises. |
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GARAGE KEEPERS |
Deductible Per Auto Two |
Enter deductible: The garage keepers comprehensive/other than collision or specified perils per auto deductible amount. |
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GARAGE KEEPERS |
Maximum Deductible Per Loss Two |
Enter deductible: The garage keepers comprehensive/other than collision or specified perils maximum deductible per loss amount. |
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GARAGE KEEPERS |
LOC # Three |
Enter number: The producer assigned number for the location. 'The location number for the physical damage coverages should correspond to a location number documented on the ACORD 125. |
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GARAGE KEEPERS |
Enter the Limits for Each Location Three |
Enter limit: The garage keepers comprehensive/other than collision or specified perils limit amount. |
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GARAGE KEEPERS |
# of Autos Three |
Enter number: The number of vehicles located on the premises. |
ACORD 138 HI (2005/01) 8 of 9
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Section Name |
Field Name |
Field and/or Section Description |
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GARAGE KEEPERS |
Deductible Per Auto Three |
Enter deductible: The garage keepers comprehensive/other than collision or specified perils per auto deductible amount. |
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GARAGE KEEPERS |
Maximum Deductible Per Loss Three |
Enter deductible: The garage keepers comprehensive/other than collision or specified perils maximum deductible per loss amount. |
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GARAGE KEEPERS |
30 (checkbox) Two |
Check the box (if applicable): Indicates autos left for service, repairs and/or storage are covered. |
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GARAGE KEEPERS |
LOC # Four |
Enter number: The producer assigned number for the location. The location number for the garage keepers coverages should correspond to a location number documented on the ACORD 125. |
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GARAGE KEEPERS |
Enter the Limits for Each Location Four |
Enter limit: The garage keepers collision limit amount. |
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GARAGE KEEPERS |
# of Autos Four |
Enter number: The number of vehicles located on the premises. |
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GARAGE KEEPERS |
Deductible Per Auto Four |
Enter deductible: The garage keepers collision per auto deductible amount. |
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GARAGE KEEPERS |
LOC # Five |
Enter number: The producer assigned number for the location. The location number for the garage keepers coverages should correspond to a location number documented on the ACORD 125. |
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GARAGE KEEPERS |
Enter the Limits for Each Location Five |
Enter limit: The garage keepers collision limit amount. |
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GARAGE KEEPERS |
# of Autos Five |
Enter number: The number of vehicles located on the premises. |
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GARAGE KEEPERS |
Deductible Per Auto Five |
Enter deductible: The garage keepers collision per auto deductible amount. |
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GARAGE KEEPERS |
LOC # Six |
Enter number: The producer assigned number for the location. The location number for the garage keepers coverages should correspond to a location number documented on the ACORD 125. |
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GARAGE KEEPERS |
Enter the Limits for Each Location Six |
Enter limit: The garage keepers collision limit amount. |
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GARAGE KEEPERS |
# of Autos Six |
Enter number: The number of vehicles located on the premises. |
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GARAGE KEEPERS |
Deductible Per Auto Six |
Enter deductible: The garage keepers collision per auto deductible amount. |
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GARAGE KEEPERS |
Additional Coverage Description |
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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GARAGE KEEPERS |
Additional Coverage Covered Auto Symbols |
Enter text: The symbols that apply to the other coverage listed. |
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GARAGE KEEPERS |
Additional Coverage Limit |
Enter limit: The limit amount of the other coverage. |
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GARAGE KEEPERS |
Physical Damage Reporting Period |
Enter text: The timing of the reporting period if the policy will be on a Reporting basis. Examples: Monthly, Quarterly, Semi-Annual. |
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Section Name |
Field Name |
Field and/or Section Description |
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GARAGE KEEPERS |
Non-Reporting Period (checkbox) |
Check the box (if applicable): Indicates the policy is on a non-reporting basis. |
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GARAGE KEEPERS |
# Dealer Plates/Repairer Plates |
Enter number: The total number of sets of dealer or repairer plates issued to the named insured. |
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GARAGE KEEPERS |
# Transportation Plates |
Enter number: The total number of sets of transportation plates issued to the applicant. |
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GARAGE KEEPERS |
# Hoists |
Enter number: The total number of hoists located on the premises. |
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GARAGE KEEPERS |
Temporary Location Limit |
Enter limit: The limit for covered autos stored temporarily off premises. |
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GARAGE KEEPERS |
Transit Limit |
Enter limit: The limit for covered autos in transit. |
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GARAGE KEEPERS |
Endorsements/Remarks |
Enter text: The remarks associated with the Garage and Dealers line of business. Enter any endorsements that apply. Be sure to include the form numbers and the required information for attaching the endorsement. |
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GARAGE KEEPERS |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. As used here, the applicant should read and understand the Fair Credit Reporting Act, the Privacy Act (where applicable), the Applicant's Statement, and any other disclosure information on the form before personally signing the application. |
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GARAGE KEEPERS |
Date |
Enter date: The date the form was signed by the named insured. |
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GARAGE KEEPERS |
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. |
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GARAGE KEEPERS |
National Producer Number |
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 138 HI (2005/01) 9 of 9
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