Form BMC-91X Motor Carrier Automobile Bodily Injury and Property Dama

U.S. DEPARTMENT

OF TANSPORTATION

A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0017. Public reporting for this collection of information is estimated to be approximately 10 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, Washington, D.C. 20590.

MOTOR CARRIER AUTOMOBILE BODILY INJURY AND PROPERTY DAMAGE LIABILITY CERTIFICATE OF INSURANCE

filed with

Received FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION Approved by OMB

Date: OFFICE OF ENFORCEMENT AND COMPLIANCE 2126-0017

Commercial Enforcement Division Expires: 02280/09

1200 New Jersey Ave, S.E.

(MC-ECC W63-106)

Washington, D.C. 20590 FMCSA Docket No.

MC________________

Filer Account No.________________ FF_________________

This is to certify, that the _________________________________________________________________________________________________________

(NAME OF INSURANCE COMPANY)

(hereinafter called Company) of_____________________________________________________________________________________________________

(HOME OFFICE ADDRESS OF INSURANCE COMPANY)

has issued to___________________________________________________________________________________________________________________

(NAME OF MOTOR CARRIER OR FREIGHT FORWARDER)

of____________________________________________________________________________________________________________________________

(ADDRESS OF MOTOR CARRIER OR FREIGHT FORWARDER)

insurance under terms described on the back of this form to provide coverage as follows: CHECK AS APPLICABLE:

Full Security Limits required in Title 49 of the Code of Federal Regulations: □ Under Section 387.303(b)(1) □ Under Section 387.303(b)(2)

Security Limits Required under Section 387.303(b)(1) or 387.303(b)(2) of the same Title as follows:

□ This insurance is primary and the company shall not be liable for amounts in excess of $ for each accident.

□ This insurance is excess and the company shall not be liable for amounts in excess of $ for each accident in excess of the underlying limit of

$ for each accident.

Effective from (12:01 a.m., standard time at the address of the Insured as stated in said policy or policies) and continuing until

canceled as provided in the rules and regulations under Section 13906 of Title 49 of the United States Code.

Countersigned at_________________________________________________________________________ Date______________________

Street Address City State Zip

Insurance Company Policy No._______________________ _____________________________________________________

(Policy No.) Issuing Office- Full Name of Agency or Branch

_____________________________________________________

(Signature of Authorized Representative)

FORM BMC-91X

The receipt of this certificate by the FMCSA certifies that a policy or policies of Public Liability (or Automobile Bodily Injury and Property Damage Liability) insurance has been issued by the company identified on the face of this form, that the company is qualified to make this filing under Section 387.315 or Section 387.411 of title 49 of the Code of Federal Regulations, and that by the attachment of endorsement BMC 90, MCS 90 or a form of similar import prescribed by the U.S. Department of Transportation, Federal Motor Carrier Safety Administration, is amended to provide the coverage or security for the protection of the public required under Section 387.303 of Title 49 of the Code of Federal Regulations. The amendment governs the operation, maintenance, or use of motor vehicles under certificate or permit issued to the insured by the Federal Motor Carrier Safety Administration or otherwise in transportation subject to Subchapter I or III of Chapter 135, of title 49 United States Code, and the pertinent rules and regulations of the Federal Motor Carrier Safety Administration, regardless of whether or not such motor vehicles are specifically described in the policy or policies or not. The liability of the Company extends to all losses, damages, injuries, or deaths occurring within the authority granted to the insured by the Federal Motor Carrier Safety Administration or elsewhere.

The endorsement(s) described herein may not be canceled or withdrawn until thirty (30) days after written notice has been submitted to the Federal Motor Carrier Safety Administration at its offices in Washington, DC, on the prescribed Form BMC‑35, Notice of Cancellation Motor Carrier Policies of Insurance under 49 U.S.C. 13906. Said thirty (30) days notice to commence to run from the date notice is actually received at the office of the FMCSA.

Falsification of this document can result in criminal penalties prescribed under 18 U.S.C. 1001.

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