ACORD MICHIGAN COMMERCIAL AUTO DATE (MM/DD/YY)
TM
COVERAGES/LIMITS SECTION
PRODUCER APPLICANT (First Named Insured)
BUSINESS AUTO SECTION
COVERAGES COVERED AUTO SYMBOLS LIMITS COVERAGES COVERED AUTO SYMBOLS LIMITS
BI
1 4 9 CSL $
EA PER
2 7 $
LIABILITY 3 8 BI EACH ACCIDENT $
PROPERTY DAMAGE
$0- $3,000- $6,000
-
INCOME $2,999 $5,999 $8,999
5
PERSONAL INJURY PROTECTION LEVEL: $9,000- $15,000 $25,00 PHYSICAL DAMAGE
7 $14,999 - 0&
OTHER: $24,999
DED $ OVER 3
TOWING
7 $
COORD COORD RJCT WK LOSS & LABOR
WK LOSS MED EXP # pers below
LIMITED PROPERTY PHYSICAL
DAMAGE LIABILITY YES5 7 EA ACCIDENT
EMPLOYEES $ 500 2 4 8 SPEC
$
NON- DAMAGE
COMPREHENSIVE
OWNED
PROPERTY
MEDICAL PROT
PAYMENTS 2
NO5 4 7 8 EA ACCIDENT $ 3 7
VOLUNTEERS
EACH PERSON $
LIABILITY 3 7
2 6 SPECIFIED 2 4 8
3 7 PARTNERS BI CAUSES OF LOSS COVERAGE IS: PRIMARY
CSL $ 3 7
4
(1) ANY AUTO EA PER
(4) OWNED AUTOS OTHER THAN PRIVATE PASSENGER (7) OS SP ECIFIED ON SCHED
COVERED MOTORIST
UNINSURED $
AUT 2 BI EACH ACCIDENT 2 4 D AU
8TOS
AUTO (2) ALL3OWNED AUTOS COLLISION
(5) ALL OWNED AUTOS WHICH REQUIRE NO-FAULT COVERAGE (8) -OW$NED AUTOS
HIRE 4 3 7
SYMBOLS (3) OWNED PRIVATE BI (6) OWNED AUTOS SUBJECT TO COMPULSORY U.M. LAW
6 PASSENGER AUTOS
CSL $ LIMITED COLL
(9) NOT
NON EA PER APPLIC
UNDERINSURED MOTORIST 7 $
BI EACH ACCIDENT BROADENED COLL
TRUCKERS SECTION
COVERAGES COVERED AUTO SYMBOLS LIMITS PHYSICAL DAMAGE
HIRED/BORROWEDYES STATES LIABILITYNO COST OF HIRE BI COVERED
41 46
STATES CSL EA PER $ IF ANY BASIS COVERAGES AUTO SYMBOLS LIMITS DEDUCTIBLE
$
GROUP STATES # YS #
LIABILITY 42 47 BI EACHTYPE
ACCIDENT $ 42 DA 46 VEH
NUMBER OF COMPREHENSIVE
HIRED COMP$ $
43 50 PROPERTY DAMAGE $ 43 47
$0- $3,000- $6,000-
INCOME $2,999 $5,999 $8,999 SPECIFIED 42 46 SCL FT LSP
$9,000- $15,00 $25,00 C OF L $
44 LEVEL: $14,99 CAUSES OF LOSS 43 47 F FT
PERSONAL INJURY 0- 0&
9 $24,99 OVER W
PROTECTION 46 9 SECONDARY
ULE
OTHER: DED $ 42 46
COORD COORD RJCT WK LOSS COLLISION $
WK LOSS MED EXP # pers below 43 47
MEDICAL 42 46 TOWING 46
EACH PERSON $ $
PAYMENTS 43 & LABOR
BI
42 46 CSL EA PER $ TRAILER INTERCHANGE
UNINSURED
43 BI EACH ACCIDENT $ COVERAGES SYMBOL # TRAILERS STAT # DAYS RADIUS DEDUCTIBLE
MOTORIST E
45
48
BI COMPREHENSIVE
42 46 CSL EA PER $ 49
UNDERINSURED
43 BI EACH ACCIDENT $ SPECIFIED 48
MOTORIST
45 CAUSES OF LOSS 49
YES STATES COST OF HIRE IF ANY BASIS 48
NON-TRUCKERS
COLLISION $
HIRED/BORROWED NO $ 49
YES STATES COST OF HIRE IF ANY BASIS STATES # DAYS # VEH
HIRED/BORROWED
LIABILITY NO $
STATES GROUP TYPE NUMBER OF HIRED
PHYSICAL
NON- YES EMPLOYEES DAMAGE
OWNED
AUTO NO VOLUNTEERS
LIABILITY COVERAGE IS: PRIMARY SECONDARY
PARTNERS
LIMITED PROPERTY NOT
DAMAGE LIABILITY 44 46 EA ACCIDENT $ 500 LIMITED COLL NO DED APPLIC APPLIC
PROPERTY PROT 44 46 EA ACCIDENT $ 1,000,000 BROADENED COLL DED $
COVERED AUTO SYMBOLS (44) OWNED AUTOS SUBJECT TO NO-FAULT (46) SPECIFICALLY DESCRIBED AUTOS (49) YOUR TRAILERS IN THE POSSESSION OF
(41) ANY AUTO (45) OWNED AUTOS SUBJECT TO A (47) HIRED AUTOS ONLY ANOTHER
TRUCKER UNDER A TRAILER
(42) OWNED AUTOS ONLY COMPULSORY UNINSURED (48) TRAILERS IN YOUR POSSESSION
UNDER INTERCHANGE AGREEMENT
(43) OWNED COMMERCIAL AUTOS ONLY MOTORIST LAW A TRAILER INTERCHANGE AGREEMENT
(50) NON-OWNED AUTOS ONLY
ACORD 137 MI (2000/09) PLEASE COMPLETE REVERSE SIDE © ACORD CORPORATION 1996
MOTOR CARRIER SECTION
COVERAGES COVERED AUTO SYMBOLS LIMITS PHYSICAL DAMAGE
BI COVERED
61 67 CSL EA PER $ COVERAGES AUTO SYMBOLS LIMITS DEDUCTIBLE
62 68 BI EACH ACCIDENT $ 62 67
LIABILITY
63 71 PROPERTY DAMAGE $ COMPREHENSIVE 63 68 $
64 64
$0- $3,000- $6,000-
INCOME $2,999 $5,999 $8,999 62 67 SCL FT LSP
LEVEL: $9,000- $15,00 $25,00 SPECIFIED
PERSONAL INJURY 65 $14,99 0- 0& 63 68 F FTW $
9 $24,99 OVER CAUSES OF LOSS
PROTECTION 67 9 64
OTHER: DED $
COORD COORD RJCT WK LOSS
WK LOSS MED EXP # pers below 62 67
LIMITED PROPERTY
DAMAGE LIABILITY 65 67 EA ACCIDENT $ 500 COLLISION 63 68 $
PROPERTY PROT 65 67 EA ACCIDENT $ 1,000,000 64
MEDICAL 62 64 TOWING 63
EACH PERSON $ $
PAYMENTS 63 67 & LABOR 67
BI
62 66 CSL EA PER $ TRAILER INTERCHANGE
UNINSURED
63 67 BI EACH ACCIDENT $ COVERAGES SYMBOL # TRAILERS STAT # DAYS RADIUS DEDUCTIBLE
MOTORIST E
64 69
BI COMPREHENSIVE
62 66 CSL EA PER $ 70
UNDERINSURED
63 67 BI EACH ACCIDENT $ SPECIFIED 69
MOTORIST
64 CAUSES OF LOSS 70
YES STATES COST OF HIRE IF ANY BASIS 69
NON-TRUCKERS
COLLISION $
HIRED/BORROWED NO $ 70
YES STATES COST OF HIRE IF ANY BASIS STATES # DAYS # VEH
HIRED/BORROWED
LIABILITY NO $
STATES GROUP TYPE NUMBER OF HIRED
PHYSICAL
NON- YES EMPLOYEES DAMAGE
OWNED
AUTO NO VOLUNTEERS
LIABILITY COVERAGE IS: PRIMARY SECONDARY
PARTNERS
OTHER NOT
LIMITED COLL NO DED APPLIC APPLIC
BROADENED COLL DED $
COVERED AUTO SYMBOLS (64) OWNED COMMERCIAL AUTOS ONLY (67) SPECIFICALLY DESCRIBED AUTOS (70) YOUR TRAILERS IN THE POSSESSION OF
(61) ANY AUTO (65) OWNED AUTOS SUBJECT TO NO-FAULT (68) HIRED AUTOS ONLY ANOTHER
TRUCKER UNDER A TRAILER
(62) OWNED AUTOS ONLY (66) OWNED AUTOS SUBJECT TO A COMPUL- (69) TRAILERS IN YOUR POSSESSION
UNDER INTERCHANGE AGREEMENT
(63) OWNED PRIVATE PASS AUTOS ONLY SORY UNINSURED MOTORIST LAW A TRAILER INTERCHANGE AGREEMENT
(71) NON-OWNED AUTOS ONLY
ENDORSEMENTS (MCCA charge will be added to the premium)
IN MAKING THIS APPLICATION FOR INSURANCE, IT IS UNDERSTOOD THAT AS A PART OF OUR UNDERWRITING PROCEDURE, AN INVESTIGATIVE
CONSUMER REPORT CONTAINING DRIVING RECORD INFORMATION MAY BE OBTAINED FOR EACH DRIVER IN THE HOUSEHOLD.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE,
INCOMPLETE, OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO ONE YEAR FOR A MISDEMEANOR
CONVICTION OR UP TO TEN YEARS FOR A FELONY CONVICTION AND PAYMENT OF A FINE OF UP TO $5,000.00.
REJECTION WORK LOSS: ALL INSUREDS PROVIDED COVERAGE UNDER THIS POLICY WHO ARE AGE 60 OR OLDER AND HAVE NO EXPECTATION OF
ACTUAL INCOME LOSS ARE ELIGIBLE TO REJECT COVERAGE FOR WORK LOSS UNDER PERSONAL INJURY PROTECTION (PIP) COVERAGE. IN ORDER FOR
THIS REJECTION TO APPLY, EACH PERSON ELIGIBLE MUST SIGN BELOW.
I (WE), THE UNDERSIGNED, HAVE READ THE ABOVE STATEMENT AND WISH TO WAIVE WORK LOSS BENEFITS AS PROVIDED UNDER THE PIP COVERAGE.
PRINT NAME SIGNATURE DATE
I HAVE BEEN INFORMED IN WRITING OF THE VARIOUS COLLISION COVERAGE OPTIONS AVAILABLE AND OF MY RIGHT OF RECOVERY UNDER EACH. I
HAVE INDICATED MY SELECTION FOR EACH VEHICLE IN THE COVERAGES/PREMIUM SECTION OF THIS APPLICATION. IF NO OPTION IS SELECTED, I
DO NOT WISH TO PURCHASE ANY COLLISION COVERAGE FOR THAT VEHICLE.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTURE
POLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
NOTE: CONSUMER ASSISTANCE MATERIAL IS AVAILABLE FROM THE MICHIGAN INSURANCE BUREAU, PO BOX 30220, LANSING, MI 48909-7720; 517-373-
0240
ACORD 137 MI
DATE
APPLICANT’S PRODUCER’S
SIGNATURE SIGNATURE
ACORD 137 MI
