Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 194 (2009/03)
Truckers / Motor Carrier
Supplement - Request for State /
Federal Filing Action
ACORD 194, Truckers / Motor Carrier Supplement Request For State
/ Federal Filing Action, is intended to supplement ACORD 132, Truckers/Motor Carrier
Section, when state or federal filing action is required and the Regulation section in
ACORD 132 is not adequate to provide the company with the necessary filing information.
Refer to your company for any specific instructions as to company-unique requirements.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION As On Policy)
Insured Identification Name (Same
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Insured Address
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION (Checkbox)
If Name/Address On Requested
Filing Should Read Differently
Than Policy-Not Applicable
Check the box (if applicable): Indicates the name and address on requested filing should
not read differently than the policy.
IDENTIFICATION SECTION Than Policy, Please Explain
If Name/Address On Requested
Filing Should Read Differently
Enter text: The full name on the requested filing. As used here, this information is
completed if the name and / or address on the requested filing should read differently than
the name and address on the policy.
IDENTIFICATION SECTION
Enter text: The first address line for the filing.
IDENTIFICATION SECTION
Enter text: The second address line for the filing.
IDENTIFICATION SECTION
Enter text: The city of the filing address.
IDENTIFICATION SECTION
Enter code: The state or province of the filing address.
IDENTIFICATION SECTION
Enter code: The postal code of the filing address.
IDENTIFICATION SECTION
Enter text: The explanation of why the name and address requested on the filing differs
from the policy.
POLICY INFORMATION
Liability Policy #
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.
POLICY INFORMATION
Liability Limit
Enter limit: The liability limit amount. As used here, this is for the liability policy.
POLICY INFORMATION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
POLICY INFORMATION
Cargo Policy #
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.
POLICY INFORMATION
Cargo Limit
Enter limit: The cargo limit amount. As used here, this is for the cargo policy.
POLICY INFORMATION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
POLICY INFORMATION
IF ICC-Regulated-Base State
Enter code: The base state or province of the truckers/motor carrier fleet.
TYPE OF AUTHORITY
AL-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
AL-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
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Section Name
Field Name
Field and/or Section Description
TYPE OF AUTHORITY
AL-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
AL-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
AK-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
AK-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
AK-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
AK-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
AZ-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
AZ-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
AZ-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
AZ-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
AR-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
AR-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
AR-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
AR-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
CA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
CA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
CA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
CA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
CO-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
CO-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
CO-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
CO-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
CT-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
CT-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
CT-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
CT-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
DE-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
DE-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
DE-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
DE-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
FL-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
FL-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
FL-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
FL-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
GA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
GA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
ACORD 194 (2009/03) rev. 03-31-2009
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Section Name
Field Name
Field and/or Section Description
TYPE OF AUTHORITY
GA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
GA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
HI-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
HI-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
HI-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
HI-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
ID-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
ID-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
ID-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
ID-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
IL-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
IL-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
IL-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
IL-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
IN-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
IN-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
IN-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
IN-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
IA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
IA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
IA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
IA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
KS-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
KS-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
KS-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
KS-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
KY-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
KY-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
KY-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
KY-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
LA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
LA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
LA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
LA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
ME-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
ME-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
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Section Name
Field Name
Field and/or Section Description
TYPE OF AUTHORITY
ME-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
ME-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
MD-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
MD-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
MD-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
MD-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
MA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
MA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
MA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
MA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
MI-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
MI-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
MI-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
MI-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
MN-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
MN-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
MN-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
MN-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
MS-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
MS-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
MS-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
MS-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
MO-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
MO-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
MO-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
MO-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
MT-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
MT-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
MT-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
MT-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
NE-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
NE-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
NE-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
NE-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
NV-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
NV-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
ACORD 194 (2009/03) rev. 03-31-2009
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Section Name
Field Name
Field and/or Section Description
TYPE OF AUTHORITY
NV-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
NV-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
NH-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
NH-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
NH-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
NH-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
NJ-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
NJ-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
NJ-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
NJ-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
NM-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
NM-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
NM-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
NM-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
NY-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
NY-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
NY-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
NY-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
NC-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
NC-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
NC-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
NC-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
ND-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
ND-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
ND-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
ND-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
OH-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
OH-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
OH-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
OH-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
OK-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
OK-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
OK-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
OK-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
OR-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
OR-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
ACORD 194 (2009/03) rev. 03-31-2009
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Section Name
Field Name
Field and/or Section Description
TYPE OF AUTHORITY
OR-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
OR-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
PA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
PA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
PA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
PA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
RI-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
RI-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
RI-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
RI-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
SC-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
SC-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
SC-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
SC-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
SD-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
SD-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
SD-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
SD-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
TN-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
TN-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
TN-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
TN-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
TX-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
TX-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
TX-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
TX-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
UT-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
UT-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
UT-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
UT-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
VT-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
VT-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
VT-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
VT-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
VA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
VA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
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Section Name
Field Name
Field and/or Section Description
TYPE OF AUTHORITY
VA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
VA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
WA-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
WA-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
WA-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
WA-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
WV-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
WV-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
WV-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
WV-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
WI-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
WI-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
WI-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
WI-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
WY-Liability-I (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is intrastate.
TYPE OF AUTHORITY
WY-Liability-E (Checkbox)
Check the box (if applicable): Indicates the liability filing authority is exempt.
TYPE OF AUTHORITY
WY-Cargo-I (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is intrastate.
TYPE OF AUTHORITY
WY-Cargo-E (Checkbox)
Check the box (if applicable): Indicates the cargo filing authority is exempt.
TYPE OF AUTHORITY
For ICC Filings: Liability MC #
Enter identifier: The liability MC number for ICC filings.
TYPE OF AUTHORITY
For ICC Filings: Cargo MC #
Enter identifier: The cargo MC number for ICC filings.
TYPE OF AUTHORITY
Canadian Province(s)
Enter text: The description of the type of filing authority for Canadian provinces.
TYPE OF AUTHORITY
Oversize / Overweight
Certificate(s)
Enter text: The description of any certificates for oversize / overweight cargo.
TYPE OF CHANGE
New (Checkbox)
Check the box (if applicable): Indicates this is a request for a new filing.
TYPE OF CHANGE
Renewal (Checkbox)
Check the box (if applicable): Indicates this is a request for a renewal of a previous filing.
TYPE OF CHANGE
Cancellation (Checkbox)
Check the box (if applicable): Indicates that a previous filing should be cancelled.
TYPE OF CHANGE
Other (Checkbox)
Check the box (if applicable): Indicates a request for a filing or a change to a filing other
than the options listed.
TYPE OF CHANGE
Other Description
Check the box (if applicable): The description of the type of filing or change to a previous
filing being requested.
REMARKS
Remarks
Enter text: The general remarks associated with the truckers / motor carrier request for
state / federal filing action.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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