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

FORM BMC-91X 

OMB No.: 2126-0017  Expiration: 02/28/2022

USDOT Number:

Date Received:

Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this
form with the Office of Management and Budget. This requirement to collect information as requested on this form does not expire.
For questions, please contact the Office of Registration and Safety Information, Registration, Licensing, and Insurance Division.
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

Motor Carrier Automobile Bodily Injury and Property Damage Liability
Certificate of Insurance

FORM BMC-91X
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

State

Postal Code

Name of Motor Carrier or Freight Forwarder

Motor Carrier’s Street Address/Route Number

City

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

for each accident.
for each accident in excess of the

(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

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-91X Page 1 of 2

Rev 12/27/20

FORM BMC-91X 

OMB No.: 2126-0017  Expiration: 02/28/2022

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. The liability of the Company extended to all losses, damages, injuries,
or death occurring within the authority granted to the insured by the Federal Motor Carrier Safety Administration or elsewhere.
The endorsement 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, 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 the FMCSA.
Falsification of this document can result in criminal penalties prescribed under 18 U.S.C. 1001.

FORM BMC-91X Page 2 of 2