Motor Carrier Forms Bodily Injury and Property Damage Liability

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1 ALPHABETICAL INDEX Forms are listed alphabetically by form title. Important Note: The forms shown herein for each state may not be a complete listing of all the motor carrier bodily injury and property damage liability forms that are required for the state. Some forms are not stocked by WOLTERS KLUWER FINANCIAL SERVICES because of their infrequent use (resulting in little demand) or because supplies are available from a state source. The state usage indicated for the various forms was based on the best information we had at the time of publication. You should be guided by individual state requirements. PAGE MC 1 of 6 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

2 FEDERAL MOTOR CARRIER ACT (D) MC1661 C 06/07 BOC3 DESIGNATION OF AGENT-MOTOR CARRIER, BROKERS AND FREIGHT FORWARDERS (E) (New) MC1651 J 03/11 BMC90 ENDORSEMENT FOR MOTOR CARRIER POLICIES OF INSURANCE FOR AUTOMOBILE BODILY INJURY AND PROPERTY DAMAGE LIABILITY UNDER SECTION 13906, TITLE 49 OF THE UNITED STATES CODE MC1612 D 10/02 MCS90B0603 ENDORSEMENT FOR MOTOR CARRIER POLICIES OF INSURANCE FOR PUBLIC LIABILITY UNDER SECTION 18 OF THE BUS REGULATORY REFORM ACT OF 1982 MC1622 P 01/07 MCS ENDORSEMENT FOR MOTOR CARRIER POLICIES OF INSURANCE FOR PUBLIC LIABILITY UNDER SECTIONS 29 AND 30 OF THE MOTOR CARRIER ACT OF 1980 (M) (New) MC1669 J 03/11 BMC91 MOTOR CARRIER AUTOMOBILE BODILY (New) MC1614 G 03/11 BMC91X MOTOR CARRIER AUTOMOBILE BODILY (FULL SECURITY LIMITS OR LEVEL OF AGGREGATION) (New) MC1709 E 03/11 BMC82 MOTOR CARRIER BODILY INJURY LIABILITY AND PROPERTY DAMAGE LIABILITY SURETY BOND UNDER U.S.C MC1711 B 06/07 MCS82B1183 MOTOR CARRIER PUBLIC LIABILITY SURETY BOND UNDER SECTION 18 OF THE BUS REGULATORY REFORM ACT OF 1982 MC1662 A 10/99 MCS MOTOR CARRIER PUBLIC LIABILITY SURETY BOND UNDER SECTION 29 AND 30 OF THE MOTOR CARRIER ACT OF 1980 (N) (New) MC1684 F 03/11 BMC36 NOTICE OF CANCELLATION MOTOR CARRIER AND BROKER'S SURETY BONDS UNDER 49 U.S.C (New) MC2440 K 03/11 BMC35 NOTICE OF CANCELLATION MOTOR CARRIER INSURANCE UNDER 49 U.S.C (P) (New) MC1603 J 03/11 BMC84 PROPERTY BROKER'S SURETY BOND UNDER 49 U.S.C (New) MC2402 G 03/11 BMC85 PROPERTY BROKER'S TRUST FUND AGREEMENT UNDER 49 USC OR NOTICE OF CANCELLATION OF THE AGREEMENT NARUC FORMS: UNIFORM MOTOR CARRIER FORMS PAGE MC 2 of 6 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

3 Developed by National Association of Regulatory and Utility Commissioners (NARUC) for use in states which have adopted the Uniform Motor Carrier Program. When an interstate carrier filing is required, use forms E, F, K, L and G. For intra-state carriers, use special state forms, except where forms E, F, K, L and G are shown for the state. * MC2445 (Form K) applies in all states except GA. * MC2446 (Form L) applies in all states except MA, MT, and RI. * (N) MC2445 A 08/99 FORM K NOTICE OF CANCELLATION OF MOTOR CARRIER INSURANCE POLICIES (FORM K) (U) MC1633 A 08/99 FORME/IRB3539B UNIFORM MOTOR CARRIER BODILY (FORM E)(USED IN MULTIPLE STATES) MC1690 A 08/99 FORM F UNIFORM MOTOR CARRIER BODILY LIABILITY INSURANCE ENDORSEMENT (FORM F)(2 PART SNAP SET) MC1632 A 08/99 FORMF/IRB3538A UNIFORM MOTOR CARRIER BODILY INJURY PROPERTY DAMAGE LIABILITY INSURANCE ENDORSEMENT (FORM F) (DOUBLE SIDED SINGLE SHEET) MC1635 A 08/99 FORM G UNIFORM MOTOR CARRIER BODILY INJURY PROPERTY DAMAGE SURETY BOND (FORM G) MC2446 A 07/99 FORM L UNIFORM NOTICE OF CANCELLATION OF MOTOR CARRIER SURETY BONDS (FORM L) GENERAL USE/STATE SPECIFIC Alaska MC1664 B 11/99 DOT UNIFORM NOTICE OF CANCELLATION OF MOTOR CARRIER INSURANCE POLICIES Arkansas AK, AL, AR, AZ, CO, CT, DC, DE, FL, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY AL, AR, AZ, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MN, MO, MS, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY PAGE MC 3 of 6 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

4 MC /71 IRB2831A CERTIFICATE (TAXICABS) California MC1730 A 08/02 DMV55MCPREV802 CALIFORNIA MOTOR CARRIER LIABILITY SURETY BOND MC2404 H 08/07 DMV65MCP MC1608 A 05/99 TL1000 (FOR USE WITH PRIVATE CARRIERS) MC /99 TL1010 (FOR USE WITH PRIVATE CARRIERS/YOUTH CAMPS) MC1679 C 01/79 TL676REV0179 (LIABILITY AND PROPERTY DAMAGE LIABILITY INSURANCE) MC1645 A 11/99 PL * (LIABILITY) MC1617 A 07/02 DTSC FOR PUBLIC LIABILITY COVERAGE MC /02 REG5009IRP0702 IRP MC1607 D 11/99 TL938REV0498* CERTIFICATE OF WORKERS COMPENSATION INSURANCE-FOR HOUSEHOLD GOODS CARRIERS, CHARTER-PARTY CARRIERS OF PASSENGERS AND PASSENGER STAGE CORPORATIONS MC /04 PE794REV0180 COMMERCIAL AIR OPERATORS AND PASSENGER AIR CARRIERS BODILY INJURY/PROPERTY DAMAGE LIABILITY MC1644 A 11/99 PL912REV1289 ENDORSEMENT (CLASS C CHARTER- PARTY CARRIERS) MC1636 A 05/99 TL-1003 ENDORSEMENT (FOR USE WITH PRIVATE CARRIERS) MC /99 TL1009 ENDORSEMENT (FOR USE WITH PRIVATE CARRIERS/YOUTH CAMPS) MC1682 D 11/99 TL675AREV0781 ENDORSEMENT (PROPERTY CARRIERS) MC2406 E 08/07 DMV67MCP INSURANCE POLICY ENDORSEMENT - CALIFORNIA MC1680 B TL568* NOTICE OF CANCELLATION MC1646 A 11/99 PL * NOTICE OF CANCELLATION (APPLIES TO PASSENGER STATE CORPORATION AND/OR CHARTER-PARTY CARRIER OF PASSENGERS) MC1626 A 05/99 TL 1002 NOTICE OF CANCELLATION (FOR USE WITH PRIVATE CARRIERS) MC2405 D 09/07 DMV66MCP NOTICE OF CANCELLATION OF INSURANCE MC1624 B 11/99 TL944* NOTICE OF CANCELLATION OF WORKERS' COMPENSATION INSURANCE MC1681 B TL394* NOTICE OF REINSTATEMENT MC1625 A 05/99 TL 1001 NOTICE OF REINSTATEMENT (FOR USE WITH PRIVATE CARRIERS) MC1647 A 11/99 PL * NOTICE OF REINSTATEMENT (LIABILITY INSURANCE) MC1638 C 11/99 TL945REV0498 NOTICE OF REINSTATEMENT OF WORKERS' COMPENSATION INSURANCE- FOR HOUSEHOLD GOODS CARRIERS, CHARTER-PARTY CARRIERS OF PASSENGERS AND PASSENGER STAGE CORPORATIONS PAGE MC 4 of 6 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

5 MC /93 TL706K WORKERS' COMPENSATION DECLARATION FORM Colorado MC /99 FORM 14-INS GARAGE KEEPERS LEGAL LIABILITY MC /99 PUC FORM 10-INS TOWING CARRIER PUBLIC LIABILITY AND PROPERTY DAMAGE INSURANCE CERTIFICATE Connecticut MC1641 B 12/99 IRB3614B INSURANCE CERTIFICATE (PUBLIC SERVICES, SCHOOL BUS AND SERVICES BUS) GU1327 G 07/09 IRB 3616D SPECIAL NOTICE OF CANCELLATION OR TERMINATION Georgia MC1726 A 04/07 FORMEGA UNIFORM MOTOR CARRIER BODILY (FORM E) MC1728 A 04/07 FORMKGA UNIFORM NOTICE OF CANCELLATION OF MOTOR CARRIER INSURANCE POLICIES (FORM K) Indiana MC /86 FORM E - IN MC /71 IRB3272A NOTICE OF REINSTATEMENT Kentucky MC1621 A 11/99 MOTOR VEHICLE DEALER BI/PD MC /88 UNIFORM MOTOR CARRIER BI/PD Maine MC1722 F 08/09 JB MV 214 STATE OF MAINE - CERTIFICATE FOR HIRE PASSENGER VEHICLE Michigan MC /97 MDOT 3007 BUS MC /98 MDOT 3046 LIMOUSINE CARRIERS MC1724 A 11/04 MDOT 3003 NOTICE OF CANCELLATION OF INSURANCE MC /95 PR PUBLIC LIABILITY INSURANCE HAZARDOUS WASTE TRANSPORTER- LIABILITY AMENDATORY ENDORSEMENT MC /95 PR PUBLIC LIABILITY INSURANCE LIQUID INDUSTRIAL WASTE TRANSPORTER LIABILITY AMENDATORY ENDORSEMENT Minnesota MC /04 COMMERCIAL VEHICLE CERTIFICATE OF INSURANCE BODILY INJURY/ PROPERTY DAMAGE LIABILITY FOR USE WITH THE METRO AIRPORTS COMMISSION MC /02 EVIDENCE OF WORKER'S COMPENSATION Montana MC1678 C 05/02 MV40500 CASUALTY INSURANCE ENDORSEMENT MC /03 MV-5 12/03 TOW TRUCKS OPERATIONS PAGE MC 5 of 6 WOLTERS KLUWER FINANCIAL SERVICES Customer Care:

6 New York MC1732 B 11/05 PERM FOR SPECIAL HAULING PERMIT, DIVISIBLE LOAD OVERWEIGHT PERMIT AND HIGHWAY WORK PERMIT INSURANCE REQUIREMENTS Ohio MC /98 BOND COVERING ANY AND ALL PERMITS ISSUED TO PRINCIPAL FOR MOVEMENTS OF EXCESS LOADS OVER STATE HIGHWAYS MC1670 B 10/08 OS ENDORSEMENT TO LIABILITY INSURANCE POLICY FOR VEHICLES OPERATING WITH A SPECIAL HAULING PERMIT ISSUED BY THE OHIO DEPARTMENT OF TRANSPORTATION MC /71 I25B POLICY CERTIFICATE (LEASED EQUIPMENT) Texas MC1628 C 06/10 FORM 1902 COMMERCIAL MOTOR VEHICLE BODILY MC1652 B 11/99 FORM1896T0895 GARAGE KEEPERS LEGAL LIABILITY West Virginia MC1604 D 04/06 MV126DSJ0406 DEALER VEHICLE LIABILITY AND PROPERTY DAMAGE CERTIFICATE OF INSURANCE MC /03 MV126DSKREV394 NOTICE OF CANCELLATION VEHICLE DEALER LIABILITY INSURANCE POLICIES Wisconsin MC1615 B 10/99 S-2 AMENDED SCHEDULE OF VEHICLES MC1610 B 10/99 B-1 (BLANKET) MC1613 B 10/99 FORM S-1 (SCHEDULE) MC1620 A 09/99 FORM FX ENDORSEMENT MC /85 FORMEX MOTOR CARRIER LIABILITY PAGE MC 6 of 6 WOLTERS KLUWER FINANCIAL SERVICES Customer Care: