Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 22 (2012/04)
Intermodal Interchange Certificate
of Insurance
ACORD 22, Intermodal Interchange Certificate of Insurance, is used
to provide a coverage statement to the Intermodal Association of North America (IANA)
when coverage being provided includes the Truckers Uniform Intermodal Interchange
Endorsement (Form UIIE-1 or CA-23-17 equivalent). Certificate preparers can check the
insurance section of the UIIA's website at www.uiia.org for further information.
IMPORTANT
Iowa, Kansas, Kentucky, Louisiana, Minnesota, Missouri, New Hampshire, North Carolina,
North Dakota, Oklahoma, Texas, Utah and Wisconsin require the filing of certificate of
insurance forms. ACORD has filed all of its certificates in these states. In these states,
the text of ACORD's certificates cannot be modified, unless the modified form is filed for
approval by the respective state Department of Insurance.
Additionally, virtually every other state will not allow any change in a certificate of
insurance that would attempt to modify a policy unless the revised certificate is filed and
approved. In these states, this form can only be changed to reflect the terms and
conditions of the policy on which it is reporting. Such change(s) must be approved in
advance by the insurance carrier that issued such policy.
IDENTIFICATION SECTION Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION Producer
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
ACORD 22 (2012/04) rev. 04-30-2012
1 of 10
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext)
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Producer Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Insured Name and Address
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
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.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
INSURERS AFFORDING
COVERAGE
Insurer A
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.
NAIC #
NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
BEST RATING
Best Rating
Enter code: The AM Best rating code for the insurer.
INSURERS AFFORDING
COVERAGE
Insurer B
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.
NAIC #
NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
BEST RATING
Best Rating
Enter code: The AM Best rating code for the insurer.
INSURERS AFFORDING
COVERAGE
Insurer C
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.
NAIC #
NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
BEST RATING
Best Rating
Enter code: The AM Best rating code for the insurer.
ACORD 22 (2012/04) rev. 04-30-2012
2 of 10
Section Name
Field Name
Field and/or Section Description
INSURERS AFFORDING
COVERAGE
Insurer D
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.
NAIC #
NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
BEST RATING
Best Rating
Enter code: The AM Best rating code for the insurer.
INSURERS AFFORDING
COVERAGE
Insurer E
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.
NAIC #
NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
BEST RATING
Best Rating
Enter code: The AM Best rating code for the insurer.
COVERAGE INFORMATION Insr Ltr General Liability
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the commercial general liability policy.
COVERAGE INFORMATION Addl Insr General Liability
Check the box (if applicable): Indicates the certificate holder has been named as an
additional insured for any of the commercial general liability policy coverages described in
the certificate.
COVERAGE INFORMATION Commercial General Liability
Check the box (if applicable): Indicates the claims made or occurrence option applies for
the general liability policy.
COVERAGE INFORMATION Claims-Made
Check the box (if applicable): Indicates the claims made option applies on the general
liability policy.
COVERAGE INFORMATION Occur
Check the box (if applicable): Indicates the general liability policy, occurrence basis
applies.
COVERAGE INFORMATION Other General Liability Checkbox
Check the box (if applicable): Indicates other coverage not found on the form exists for the
general liability policy.
COVERAGE INFORMATION Other General Liability Description
Enter text: The description of other coverage (not the limit) on the general liability policy.
Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
COVERAGE INFORMATION Other General Liability Checkbox
Check the box (if applicable): Indicates other coverage not found on the form exists for the
general liability policy.
COVERAGE INFORMATION Other General Liability Description
Enter text: The description of other coverage (not the limit) on the general liability policy.
Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
COVERAGE INFORMATION Per: - Policy
General Aggregate Limit Applies
Check the box (if applicable): Indicates the general liability policy, general aggregate limit
applies per policy.
COVERAGE INFORMATION Per: - Other
General Aggregate Limit Applies
Check the box (if applicable): Indicates the general liability policy, general aggregate limit
applies to code is other than those listed.
ACORD 22 (2012/04) rev. 04-30-2012
3 of 10
Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION Per: - Other Description
General Aggregate Limit Applies
Enter code: The limit applies to code for the general liability policy, general aggregate limit.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the general liability 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.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Effective Date
Enter date: The effective date of the general liability policy. The date that the terms and
conditions of the policy commence.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Expiration Date
Enter date: The date on which the terms and conditions of the general liability policy will
expire.
COVERAGE INFORMATION Each Occurrence
Enter limit: The general liability, each occurrence limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION Damage to Rented Premises
Enter limit: The general liability, damage to rented premises each occurrence limit
amount. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
COVERAGE INFORMATION Med Exp
Enter limit: The general liability, medical expense each person limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGE INFORMATION Personal & Adv Injury
Enter limit: The general liability, personal and advertising injury limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
COVERAGE INFORMATION General Aggregate
Enter limit: The general liability, general aggregate limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION Products - Comp/Op Agg
Enter limit: The general liability, products and completed operations aggregate limit
amount. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
COVERAGE INFORMATION Other Limit Description
Enter limit: The general liability, other coverage limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION Other Limit
Enter text: The description of other coverage (not the limit). Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the policy.
ACORD 22 (2012/04) rev. 04-30-2012
4 of 10
Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION Addl Insr
Check the box (if applicable): Indicates the certificate holder has been named as an
additional insured for any of the vehicle policy coverages described in the certificate.
COVERAGE INFORMATION Any Auto
Check the box (if applicable): Indicates the commercial vehicle policy covers any auto.
COVERAGE INFORMATION All Owned Autos
Check the box (if applicable): Indicates the commercial vehicle policy covers all owned
autos.
COVERAGE INFORMATION Scheduled Autos
Check the box (if applicable): Indicates the vehicle policy covers scheduled autos.
COVERAGE INFORMATION Hired Autos
Check the box (if applicable): Indicates the vehicle policy covers hired autos.
COVERAGE INFORMATION Non-Owned Autos
Check the box (if applicable): Indicates the vehicle policy covers non-owned autos.
COVERAGE INFORMATION Other Automobile Liability
Check the box (if applicable): Indicates other coverage not found on the form exists for the
vehicle policy.
COVERAGE INFORMATION Other Automobile Liability - Field
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).
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the automobile liability 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.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Effective Date
Enter date: The effective date of the automobile liability policy. The date that the terms
and conditions of the policy commence.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Expiration Date
Enter date: The date on which the terms and conditions of the automobile liability policy
will expire.
COVERAGE INFORMATION Combined Single Limit
Enter limit: The vehicle combined single limit liability each accident amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGE INFORMATION Bodily Injury ( Per Person)
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).
COVERAGE INFORMATION Bodily Injury (Per 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).
ACORD 22 (2012/04) rev. 04-30-2012
5 of 10
Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION 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).
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the motor truck cargo policy.
COVERAGE INFORMATION Addl Insr
Check the box (if applicable): Indicates the certificate holder has been named as an
additional insured for any of the motor truck cargo policy coverages described in the
certificate.
COVERAGE INFORMATION Per Vehicle Ded
Enter deductible: The deductible amount for the coverage.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the cargo 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.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Effective Date
Enter date: The effective date of the cargo policy. The date that the terms and conditions
of the policy commence.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Expiration Date
Enter date: The date on which the terms and conditions of the cargo policy will expire.
COVERAGE INFORMATION Limits
Enter limit: The cargo limit amount.
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the trailer interchange portion of the vehicle
policy.
COVERAGE INFORMATION Addl Insr
Check the box (if applicable): Indicates the certificate holder has been named as an
additional insured for any of the trailer interchange coverages described in the certificate.
COVERAGE INFORMATION Per Trailer Ded
Enter deductible: The deductible amount applicable to trailer interchange collision
coverage.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the trailer interchange physical
damage 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.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Effective Date
Enter date: The effective date of the trailer interchange physical damage policy. The date
that the terms and conditions of the policy commence.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Expiration Date
Enter date: The date on which the terms and conditions of the trailer interchange physical
damage policy will expire.
ACORD 22 (2012/04) rev. 04-30-2012
6 of 10
Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION Limit Per Trailer
Enter limit: The per trailer limit amount for trailer interchange collision coverage.
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the commercial excess umbrella liability policy.
COVERAGE INFORMATION Addl Insr
Check the box (if applicable): Indicates the certificate holder has been named as an
additional insured for any of the commercial excess umbrella liability policy coverages
described in the certificate.
COVERAGE INFORMATION Umbrella Liab
Check the box (if applicable): Indicates the type of policy is umbrella.
COVERAGE INFORMATION Excess Liab
Check the box (if applicable): Indicates the type of policy is excess.
COVERAGE INFORMATION Occur
Check the box (if applicable): Indicates coverage trigger is on an occurrence basis on an
excess or umbrella liability policy.
COVERAGE INFORMATION Claims-Made
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis
on an excess or umbrella liability policy.
COVERAGE INFORMATION Deductible
Check the box (if applicable): This indicates whether a deductible or retention amount
applies to the excess or umbrella liability policy.
COVERAGE INFORMATION Retention
Check the box (if applicable): Indicates the excess or umbrella liability policy has an
applicable deductible or retention amount.
COVERAGE INFORMATION Amount $
Enter deductible: The excess or umbrella liability deductible or retention amount.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the excess liability 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.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Effective Date
Enter date: The effective date of the excess liability policy. The date that the terms and
conditions of the policy commence.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Expiration Date
Enter date: The date on which the terms and conditions of the excess liability policy will
expire.
COVERAGE INFORMATION Each Occurrence
Enter limit: The excess umbrella liability limit each occurrence limit.
COVERAGE INFORMATION Aggregate
Enter limit: The excess/umbrella liability aggregate limit should be listed as whole dollar
amount, as found on the policy declarations page. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s).
ACORD 22 (2012/04) rev. 04-30-2012
7 of 10
Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION Other Limit
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
COVERAGE INFORMATION Other Limit Amount
Enter limit: The excess umbrella liability limit other coverage limit. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION Other Limit
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
COVERAGE INFORMATION Other Limit Amount
Enter limit: The excess umbrella liability limit other coverage limit. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the commercial workers compensation and
employers liability policy.
COVERAGE INFORMATION Liability
Type of Insurance - Workers
Compensation and Employers'
Enter Y for a Yes response. Input N for No response. Indicates whether the workers
compensation and employers liability policy excludes any proprietor, partner, executive
officer, or member.
COVERAGE INFORMATION Policy Number
Enter identifier: The identifier assigned by the insurer to the workers compensation and
employers liability 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.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Effective Date
Enter date: The effective date of the workers compensation and employers liability policy.
The date that the terms and conditions of the policy commence.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Expiration Date
Enter date: The date on which the terms and conditions of the workers compensation and
employers liability policy will expire.
COVERAGE INFORMATION WC Statutory Limits
Check the box (if applicable): Indicates that workers compensation statutory limits apply.
COVERAGE INFORMATION Other
Check the box (if applicable): Indicates that additional coverage above the workers
compensation statutory limits applies (permitted in some states). Describe the additional
coverage in the Special Provisions section.
COVERAGE INFORMATION Field Box
Enter text: The description of other coverage (not the limit) on the workers compensation
and employers liability policy. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
ACORD 22 (2012/04) rev. 04-30-2012
8 of 10
Section Name
Field Name
Field and/or Section Description
COVERAGE INFORMATION E.L. Each Accident
Enter limit: The workers compensation and employers liability policy, employers liability
each accident limit amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION E.L. Disease - Ea Employee
Enter limit: The workers compensation and employers liability policy, employers liability
disease each employee limit amount. Any questions about appropriate limits or applicable
policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION E.L. Disease - Policy Limit
Enter limit: The workers compensation and employers liability policy, employers liability
disease policy limit amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Insr Ltr
Enter code: The Company Letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the other policy.
COVERAGE INFORMATION Type of Insurance - Other
Enter text: The description of the other policy not listed on the form.
COVERAGE INFORMATION Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including
prefix and suffix symbols.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Effective Date
Enter date: The date on which the terms and conditions of the other policy commence.
COVERAGE INFORMATION (MM/DD/YYYY)
Policy Expiration Date
Enter date: The date on which the terms and conditions of the other policy expires.
COVERAGE INFORMATION Limits
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Interchange Endorsement
The Truckers Uniform Intermodal
Check the box (if applicable): Indicates the Truckers Uniform Intermodal Interchange
Endorsement (Form UIIE-1 or CA 23-17 equivalent) is part of the auto policy(ies). The
attached list of providers are additional insureds in
regards to the auto liability. Those providers with (*) are additional insureds on the general
liability and those with (**) are additional insureds on trailer interchange coverage.
COVERAGE INFORMATION Provisions
Description of Operations /
Locations / Vehicles / Exclusions
Added by Endorsement / Special
Enter text: The Certificate Of Liability Insurance general remarks. The additional
comments or special conditions that may exist upon the policy. ACORD 101, Additional
Remarks Schedule, may be attached if more space is required.
ACORD 22 (2012/04) rev. 04-30-2012
9 of 10
Section Name
Field Name
Field and/or Section Description
CANCELLATION
Authorized Representative
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.
As used here, please note that insureds may be subject to cancellation requirements as a
result of their participation in the Uniform Intermodal Interchange & Facilities Access
Agreement (UIIA). Certificate preparers can check the insurance section of the UIIA's
website at www.uiia.org for more information.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 22 (2012/04) rev. 04-30-2012
10 of 10