Form BMC-34 Household Goods Motor Carrier Cargo Liability Certificat

FORM BMC-34

OMB No.: 2126-0017

Revised 06/04/2015

USDOT Number:

Expiration: 02/28/2017

Date Received:

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.

United States Department of Transportation
Federal Motor Carrier Safety Administration

Household Goods Motor Carrier Cargo Liability
Certificate of Insurance

FORM BMC-34
This is to certify, that the

Name of Insurance Company

(hereinafter called Company) of
has issued to
of

Company’s Home Office Street Address/Route Number

City

YT
WY
WV
WI
WA
VT
VI
VA
UT
TX
TN
SK
SD
SC
RI
QC
PW
PR
PE
PA
OR
ON
OK
OH
NY
NV
NU
NT
NS
NM
NL
NJ
NH
NE
ND
NC
NB
MT
MS
MP
MO
MN
MI
MH
ME
MD
MB
MA
LA
KY
KS
IN
IL
ID
IA
HI
GU
GA
FM
FL
DE
DC
CT
CO
CA
BC
AZ
AS
AR
AL
AK
AB
State

Postal Code

YT
WY
WV
WI
WA
VT
VI
VA
UT
TX
TN
SK
SD
SC
RI
QC
PW
PR
PE
PA
OR
ON
OK
OH
NY
NV
NU
NT
NS
NM
NL
NJ
NH
NE
ND
NC
NB
MT
MS
MP
MO
MN
MI
MH
ME
MD
MB
MA
LA
KY
KS
IN
IL
ID
IA
HI
GU
GA
FM
FL
DE
DC
CT
CO
CA
BC
AZ
AS
AR
AL
AK
AB
State

Postal Code

Name of Motor Carrier

Motor Carrier’s Street Address/Route Number

City

a policy or policies of Cargo Insurance under terms described on the back of this form.
(12:01 a.m., standard time at the address of the Insured as stated in said policy or policies)
Effective from
and continuing until canceled as provided in the rules and regulations under Section 13906 of Title 49 of the United States Code.
Countersigned at:

City

YT
WY
WV
WI
WA
VT
VI
VA
UT
TX
TN
SK
SD
SC
RI
QC
PW
PR
PE
PA
OR
ON
OK
OH
NY
NV
NU
NT
NS
NM
NL
NJ
NH
NE
ND
NC
NB
MT
MS
MP
MO
MN
MI
MH
ME
MD
MB
MA
LA
KY
KS
IN
IL
ID
IA
HI
GU
GA
FM
FL
DE
DC
CT
CO
CA
BC
AZ
AS
AR
AL
AK
AB
State

Postal Code

Insurance Company Policy Number:

Date:
Issuing Office:

Street Address/Route Number of Countersigning Location

Full Name of Agency or Branch

Countersigned by:

Signature of Authorized Representative

Filings must be transmitted online via the Internet at http://www.fmcsa.dot.gov/urs.

(continued on next page)
FORM BMC-34 Page 1 of 2

FORM BMC-34

OMB No.: 2126-0017

Revised 06/04/2015

Expiration: 02/28/2017

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

FORM BMC-34 Page 2 of 2