Form BMC-34 Household Goods Motor Carrier Cargo Liability Certificat

U.S. DEPARTMENT OF TRANSPORTATION

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.

Form BMC-34 To be sent to: FMCSA Office of Enforcement and Compliance Commercial Enforcement Division (MC-ECC W63-105) 1200 New Jersey Ave., S.E. Washington, D.C. 20590

HOUSEHOLD GOODS MOTOR CARRIER CARGO LIABILITY CERTIFICATE OF INSURANCE filed with FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION OFFICE OF ENFORCEMENT AND COMPLIANCE Commercial Enforcement Division Washington, D.C. 20590

Approved by OMB 2126-0017 Expires: FMCSA Docket No. MC       FF      

Received:       Filer Account No.      

Date:      

This is to certify, that the      

(NAME OF COMPANY)

(hereinafter called Company) of      

(HOME OFFICE ADDRESS OF COMPANY)

has issued to      

(NAME OF MOTOR CARRIER)

of      

(ADDRESS OF MOTOR CARRIER)

a policy or policies of Cargo Insurance under terms described on the back of this form.

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 Number) (Issuing Office ‑ Full Name of Agency or Branch)

(Signature of Authorized Representative)

MC2439h (05-09) Wolters Kluwer Financial Services | Uniform Forms^TM

The receipt of this certificate by the FMCSA certifies that a policy or policies of cargo 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 32 prescribed by the Federal Motor Carrier Safety Administration, is amended to provide compensation for loss of or damage to all property belonging to shippers or consignees and coming into the possession of the insured in connection with its transportation service under certificate issued to the insured by the Federal Motor Carrier Safety Administration or otherwise under Chapter 139, of Title 49 United States Code, and the pertinent rules and regulations of the Federal Motor Carrier Safety Administration, regardless of whether or not the motor vehicles, terminals, warehouses, and other facilities used in connection with the transportation of such property are specifically described in the policy or policies. The liability of the Company extends to such losses or damages whether occurring on the route or in the territory authorized to be served by the insured or elsewhere.

Whenever requested by the FMCSA, the Company agrees to furnish to the FMCSA a duplicate original of said policy or policies and all endorsements thereon.

The endorsement described herein may not be canceled without cancellation of the policy (or policies) to which it is attached. Such cancellation may be effected by the Company or the Insured giving thirty (30) days notice in writing to the Federal Motor Carrier Safety Administration at its offices in Washington, D.C., 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 said FMCSA.

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

MC2439h (05-09)