Form BMC-40 Application for Authority to Self-Insure Under 49 U.S.C.

FORM BMC-40 Instructions

OMB No.: 2126-0017

Revised 06/05/2015

Expiration: 02/28/2017

United States Department of Transportation
Federal Motor Carrier Safety Administration

FMCSA Office of Registration and Safety Information
Application for Authority to Self-Insure Under 49 U.S.C. 13906

INSTRUCTIONS for FORM BMC-40

1. This application must be filed in accordance with the provisions of 49 CFR 387.309 (“Qualifications as self-insurer and other
securities or agreements”) — This regulation is reprinted below.
2. Exhibits must be typed on paper 8½×11 or folded to conform — The applicant’s name should appear on the top of each page
thereof.
3. The name of each person signing this application must be typed or printed beneath the signature.
4. All information required must be given, unless neither known nor available to applicant without reasonable effort or
expense — In such case, explicit statements to such effect shall be provided in lieu of the omitted material, setting forth the
reasons why the information is not known or available.
5. A filing fee must accompany the application — Since these fees are subject to change, please contact the Federal Motor Carrier
Safety Administration (FMCSA) regarding current fees.
6. There should be filed with the FMCSA three true copies of the application for use by the FMCSA.

Section 387.309
Qualifications as a self-insurer and other securities or agreements
a. As a self-insurer — The Federal Motor Carrier Safety Administration will consider and will approve, subject to appropriate and
reasonable conditions, the application of a motor carrier to qualify as a self-insurer, if the carrier furnishes a true and accurate
statement of its financial condition and other evidence that establishes to the satisfaction of the FMCSA the ability of the
motor carrier to satisfy its obligations for bodily injury liability, property damage liability, or cargo liability.
Application Guidelines: In addition to filing Form BMC-40, applicants for authority to self-insure against bodily injury and property
damage claims should submit evidence that will allow the Federal Motor Carrier Safety Administration to determine:
1. The adequacy of the tangible net worth of the motor carrier in relation to the size of operations and the extent of
its request for self-insurance authority — Applicant should demonstrate that it will maintain a net worth that will ensure
that it will be able to meet its statutory obligations to the public to indemnify all claimants in the event of loss.
2. The existence of a sound self-insurance program — Applicant should demonstrate that it has established, and will
maintain, an insurance program that will protect the public against all claims to the same extent as the minimum security
limits applicable to applicant under §387.9 and §387.33 of this part. Such a program may include, but not be limited to, one
or more of the following:
•
•
•
•
•
•
•

irrevocable letters of credit
irrevocable trust funds
reserves
sinking funds
third-party financial guarantees, parent company, or affiliate sureties
excess insurance coverage
or other similar arrangements.

3. The existence of an adequate safety program — Applicant must submit evidence of a current “satisfactory” safety rating
by the United States Department of Transportation. Non-rated carriers need only certify that they have not been rated.
Applications by carriers with a less than satisfactory rating will be summarily denied. Any self-insurance authority granted
by the Federal Motor Carrier Safety Administration will automatically expire 30 days after a carrier receives a less than
satisfactory rating from DOT.
4. Additional information — Applicant must submit such additional information to support its application as the Federal
Motor Carrier Safety Administration may require.
b. Other securities or agreements — The Federal Motor Carrier Safety Administration will also consider applications for
approval of other securities or agreements and will approve any such application if satisfied that the security or agreement
offered will afford the security for protection of the public contemplated by 49 USC 13906.

FORM BMC Instructions • Page I of I

FORM BMC-40

OMB No.: 2126-0017

Revised 06/05/2015

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 40 hours 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

FMCSA Office of Registration and Safety Information
Application for Authority to Self-Insure Under 49 U.S.C. 13906

FORM BMC-40

NOTE: Read Instructions before answering.
A false statement in this application is punishable by law.

Applicant Information
Applicant’s Legal Name

Business Address (actual street address):
Street Address/Route Number

American
Alberta
Alaska
Alabama
British
Arkansas
Arizona
District
Delaware
Connecticut
Colorado
California
Marshall
Manitoba
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Micronesia
Michigan
Massachusetts
Maryland
New
Newfoundland
North
Northern
Northwest
Nova
Prince
Pennsylvania
Palau
Oregon
Ontario
Oklahoma
Ohio
Nunavut
Puerto
Rhode
Quebec
Saskatchewan
South
Virgin
Vermont
Utah
Texas
Tennessee
West
Washington
Virginia
Yukon
Wyoming
Wisconsin
Brunswick
Hampshire
Jersey
Mexico
Virginia
Scotia
Carolina
Dakota
Carolina
Dakota
Edward
Island
Islands
Columbia
Rico
ofIslands
Marianas
Samoa
Columbia
Territories
Island
and Labrador
State orYork
Province

City

Postal Code

Telephone (+ area code)

E-mail Address

Mailing Address (if different from above; mailing address may be given but actual street address must be shown):
Street Address/Route Number

American
Alberta
Alaska
Alabama
British
Arkansas
Arizona
District
Delaware
Connecticut
Colorado
California
Marshall
Manitoba
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Micronesia
Michigan
Massachusetts
Maryland
New
Newfoundland
North
Northern
Northwest
Nova
Prince
Pennsylvania
Palau
Oregon
Ontario
Oklahoma
Ohio
Nunavut
Puerto
Rhode
Quebec
Saskatchewan
South
Virgin
Vermont
Utah
Texas
Tennessee
West
Washington
Virginia
Yukon
Wyoming
Wisconsin
Brunswick
Hampshire
Jersey
Mexico
Virginia
Scotia
Carolina
Dakota
Carolina
Dakota
Edward
Island
Islands
Columbia
Rico
ofIslands
Marianas
Samoa
Columbia
Territories
Island
and Labrador
State orYork
Province

City

Postal Code

Telephone (+ area code)

E-mail Address

Form of Business (applicant must check one of the following and provide any additional information, if pertinent, in the space provided):
Corporation (give State of incorporation):
Partnership (identify each of the partners):
Sole Proprietorship
Other (please specify):

FORM BMC-40 Page 1 of 6

FORM BMC-40

OMB No.: 2126-0017

Revised 06/05/2015

Expiration: 02/28/2017

Applicant’s Representative to whom inquiries may be made
(if you are the applicant you may represent yourself; if so, put your name and address here):
Applicant’s Representative Name

Street Address/Route Number

City

American
Alberta
Alaska
Alabama
British
Arkansas
Arizona
District
Delaware
Connecticut
Colorado
California
Marshall
Manitoba
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Micronesia
Michigan
Massachusetts
Maryland
New
Newfoundland
North
Northern
Northwest
Nova
Prince
Pennsylvania
Palau
Oregon
Ontario
Oklahoma
Ohio
Nunavut
Puerto
Rhode
Quebec
Saskatchewan
South
Virgin
Vermont
Utah
Texas
Tennessee
West
Washington
Virginia
Yukon
Wyoming
Wisconsin
Brunswick
Hampshire
Jersey
Mexico
Virginia
Scotia
Carolina
Dakota
Carolina
Dakota
Edward
Island
Islands
Columbia
Rico
ofIslands
Marianas
Samoa
Columbia
Territories
Island
and Labrador
State orYork
Province

Postal Code

Telephone (include area code)

E-mail Address

This is an application to self-insure under the provisions of Section 13906 of Title 49 security requirements, for operations
conducted or pending under the FMCSA.
Certificate #:

Permit #:

Docket #:

Applicant hereby applies for authority to self-insure (check all that apply):
Bodily Injury and Property Damage (BI&PD) Liability

Cargo Liability

Where self-insurance authority for bodily injury and property damage is requested for an amount less than the full required
limits of liability, state the amount of coverage desired:
$
Exhibits

A

B

C are attached hereto and made a part hereof.

Applicant Certification
WHEREFORE, applicant prays that the Federal Motor Carrier Safety Administration will authorize the self-insurance proposed herein:
Dated this

31st
30th
29th
28th
27th
26th
25th
24th
23rd
22nd
21st
20th
19th
18th
17th
16th
15th
14th
13th
12th
11th
10th
9th
8th
7th
6th
5th
4th
3rd
2nd
1st

day of

December
November
October
September
August
July
June
May
April
March
February
January

, in the year

2017
2016
2015
2014

Applicant’s Legal Name

Applicant Representative’s Signature

Applicant Representative’s Title

Street Address/Route Number

City

American
Alberta
Alaska
Alabama
British
Arkansas
Arizona
District
Delaware
Connecticut
Colorado
California
Marshall
Manitoba
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Micronesia
Michigan
Massachusetts
Maryland
New
Newfoundland
North
Northern
Northwest
Nova
Prince
Pennsylvania
Palau
Oregon
Ontario
Oklahoma
Ohio
Nunavut
Puerto
Rhode
Quebec
Saskatchewan
South
Virgin
Vermont
Utah
Texas
Tennessee
West
Washington
Virginia
Yukon
Wyoming
Wisconsin
Brunswick
Hampshire
Jersey
Mexico
Virginia
Scotia
Carolina
Dakota
Carolina
Dakota
Edward
Island
Islands
Columbia
Rico
ofIslands
Marianas
Samoa
Columbia
Territories
Island
and Labrador
State orYork
Province

Postal Code

Each person by whom this application is signed certifies that the representations appearing in said application and exhibits attached thereto
(including any accompanying schedules or statements) are, to the best of his/her knowledge and belief, true, correct, and complete, based on
all the information required to be included therein, of which he/she has any knowledge, and these representations are made in good faith.
Dated this

31st
30th
29th
28th
27th
26th
25th
24th
23rd
22nd
21st
20th
19th
18th
17th
16th
15th
14th
13th
12th
11th
10th
9th
8th
7th
6th
5th
4th
3rd
2nd
1st

day of

December
November
October
September
August
July
June
May
April
March
February
January

, in the year

2017
2016
2015
2014

Applicant’s Legal Name

Applicant Representative’s Signature

Applicant Representative’s Title

FORM BMC-40 Page 2 of 6

FORM BMC-40

OMB No.: 2126-0017

Revised 06/05/2015

Expiration: 02/28/2017

Exhibit A: General Interrogatories
Applicant’s Legal Name

1. Have you qualified as a self-insurer in any State?

Yes

No

If “yes" furnish full particulars:

2. Has your authority to self-insure in any State ever been revoked?

Yes

No

If “yes" give reasons:

3. Has your application to any State for permission to qualify as a self-insurer ever been declined?

Yes

No

If “yes" give reasons:

4. Have you made or will you make application to all States in which you operate
for authority to self-insure to the same extent application is made herein?

Yes

No

If “no" explain:

5. Attach statement giving the following information for each of the past three
years for each class of insurance you desire to self-insure:
(a) Names and addresses of insurance companies who have insured your operations.
(b) Provide information concerning the following:
• Premium history;
• Losses and loss expenses paid by insurer, broken down to show those claims settled and those in
reserve; and
• Breakdown of claims within your self-insured retention and those in excess thereof, by number of
claims and aggregate of losses.
(c) Your sources of information for the above data.

FORM BMC-40 Page 3 of 6

ATTACH FILE

FORM BMC-40

OMB No.: 2126-0017

Revised 06/05/2015

Expiration: 02/28/2017

6. Give complete details of your present insurance coverage for each type of insurance you desire to selfinsure, including the name of insurance company, limits of liability, and deductibles, if any:

7. If you presently handle any of your own claims under a deductible provision, state
the amount of said deductible, and type of coverage involved:

8. If your application to self-insure is approved, what excess insurance, if any, do you intend to carry thereafter?

(a) With what insurer?
(b) Have you obtained a firm commitment from an excess insurer?

Yes

No

Name of insurance company:
9. Has your insurance on any type of risk been canceled by any insurance company during the past five years?

Yes

No

If “yes" give full particulars:

10. Attach a statement outlining, in detail, the nature and scope of your operation, including: (a) the commodities
you intend to transport; (b) the territory to be served (general description); (c) number and type of equipment to
be operated; and (d) location of headquarters and terminal facilities.
11. (a) Attach a statement outlining, in detail, the operation of your present safety program, if any. This must include,
as a minimum, the names, duties, experience, and length of service of each person devoting full-time to safety.
Also furnish the same information for those persons engaging in safety work-part-time (giving approximate
percentage of time).
(b) Have you received a safety rating from the U.S. Department of Transportation?
If “yes” what is your current rating?

FORM BMC-40 Page 4 of 6

Yes

No

ATTACH FILE

ATTACH FILE

FORM BMC-40

OMB No.: 2126-0017

Revised 06/05/2015

12. (a) Do you maintain a salaried or other claims department personnel?

Yes

Expiration: 02/28/2017

No

(b) If “yes” attach a statement outlining, in detail, the names, duties, experience, and length of service of each
person devoting full time to said claims work. Also furnish the same information for those person engaging in
claims work part-time (giving approximate percentage of time).

ATTACH FILE

13. What do you estimate your annual savings will be if your application to self-insure is approved?
14. Explain briefly how you arrived at the figure in question 13, above.

15. For what reason(s), other than potential money savings, do you desire to self-insure?

Exhibit B: Instructions relating to information to be included in Exhibits B and C
Applicant should submit the following information:
1. Balance sheets, income statements and statements of cash flows, in conformance with generally accepted accounting principles, for
the latest available period of the current year and the previous two calendar years. If two or more affiliates are requesting self-insurance approval in a single application, separate financial statements for each applicant should be submitted.
2. If available, an outside auditor’s most recent financial statements, including accompanying notes to these statements.
3. If an individual or a corporation will act as a surety for applicant’s self-insurance claims, the proposed surety’s latest financial statements (balance sheets, income statement and statement of case flows) in conformance with generally accepted accounting principles.
4. Full disclosure of receivables due from affiliated companies and stockholders, and payables due to affiliated companies and stockholders. This includes disclosure of amounts, names, terms and conditions.
5. Full disclosure of terms and conditions in regard to liabilities to financial institutions. This includes interest rates, maturity dates,
assets pledged and restrictive covenants.
In addition to the financial statement data described above, the applicant should attach a statement describing the sources of funds
that will be used to pay self-insurance claims. Specifically, applicant should indicate if an irrevocable letter of credit or an irrevocable
trust fund will be established and maintained for the sole purpose of paying such claims. Pertinent details should be provided, such as
amount of the letter of credit or trust fund, the financial institution where funds will be deposited, and the terms and conditions of the
arrangement, if available.
ATTACH FILE

FORM BMC-40 Page 5 of 6

FORM BMC-40

OMB No.: 2126-0017

Revised 06/05/2015

Expiration: 02/28/2017

Exhibit C
Attach the following as separate exhibits identifying them as follows:

Exhibit “C 1”
Copies of all resolutions of stockholders or director authorizing this application. If the charter or bylaws require approval by the
stockholders, copies of resolutions of the stockholders authorizing this application for self-insuring under 49 U.S.C. 13906 and indicate
the percentage of stock voting for such authorization.

Exhibit “C 2”
Copies of all resolutions of stockholders or director, or duly authorized committees thereof, designating by name and for that purpose
the executive officer by whom the application is signed and verified, and filed on behalf of the applicant.

Exhibit “C 3”
If an organization other than a corporation is an applicant, there shall be furnished documentary evidence showing authorization and
designation of the individuals signing, verifying, and filing on behalf of the applicant.
ATTACH FILE

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

FORM BMC-40 Page 6 of 6