Fillable Form 5: NEW JERSEY COMMERCIAL AUTO (First Choice Insurance Intermediaries)

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Form 5: NEW JERSEY COMMERCIAL AUTO (First Choice Insurance Intermediaries)

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SIGNATURE
APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE
COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT RENEWALS. SUCH INFORMATION
AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD
PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF
ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST.
CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL
PENALTIES.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTURE POLICY
RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
The ACORD name and logo are registered marks of ACORD
ENDORSEMENTS / REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
EFFECTIVE DATE:
NAMED INSURED(S)
POLICY NUMBER
NAIC CODE
CARRIER
AGENCY
AGENCY CUSTOMER ID:
COLLISION
2
3
4
7
8
CAUSES OF LOSS
SPECIFIED
2
3
4
7
8
& LABOR
TOWING
3
7
$
2
3
4
7
8
OTHER THAN
COLLISION
COST OF HIRE IF ANY BASIS
$
LIABILITY
HIRED / BORROWED
STATESYES
NO
NUMBER OF
PARTNERS
VOLUNTEERS
EMPLOYEES
GROUP TYPE
LIABILITY
NON-OWNED
NO
YES STATES
COVERED
AUTO
SYMBOLS
(9) NON-OWNED AUTOS
(8) HIRED AUTOS
(7) AUTOS SPECIFIED ON SCHEDULE
(6) OWNED AUTOS SUBJECT TO COMPULSORY U.M. LAW
(5) ALL OWNED AUTOS WHICH REQUIRE NO-FAULT COVERAGE
(4) OWNED AUTOS OTHER THAN PRIVATE PASSENGER
(3) OWNED PRIVATE PASSENGER AUTOS
(2) ALL OWNED AUTOS
(1) ANY AUTO
BUSINESS AUTO SECTION
LIMITSCOVERED AUTO SYMBOLSCOVERAGES
CSL
BI
EA PER
BI EACH ACCIDENT
PROPERTY DAMAGE
$
$
$
9
8
7
4
3
2
1
LIABILITY
LIMITSCOVERED AUTO SYMBOLSCOVERAGES
PHYSICAL DAMAGE
MOTORIST
UNDERINSURED
UNINSURED /
7
6
4
3
2
$
$
$
PROPERTY DAMAGE
BI EACH ACCIDENT
EA PER
BI
CSL
NUMBER OF RELATIVES:EXTRA PIP OPTIONS
SECONDARYPRIMARYCOVERAGE IS:
$
$
$
COLL
C OF L
SPEC
OTC
COVERAGE / DEDUCTIBLE# VEH# DAYSSTATES
DAMAGE
PHYSICAL
HIRED
$
$
$
DED
MEDICAL EXPENSE
NO THRESHOLD
MEDICAL ONLYLAWSUIT THRESHOLD
NOYESHEALTH INSURANCE OPTION
EXT MED EXP EA PER
PERSONAL
INJURY
PROTECTION
5
7
DATE (MM/DD/YYYY)
COVERAGES / LIMITS SECTION
NEW JERSEY COMMERCIAL AUTO
© 1996-2008 ACORD CORPORATION. All rights reserved.ACORD 137 NJ (2008/08) Page 1 of 3
ENDORSEMENTS / REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
ACORD 137 NJ (2008/08) Page 2 of 3
SIGNATURE
APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE
COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT RENEWALS. SUCH INFORMATION
AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD
PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF
ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST.
CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL
PENALTIES.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTURE POLICY
RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
AGENCY CUSTOMER ID:
OTHER
$
46
& LABOR
TOWING
$
47
46
43
42
COLLISION
47
46
43
42
$
OTHER THAN
COLLISION
SPECIFIED
CAUSES OF LOSS
47
46
43
42
$
SCL
F
FT
FTW
LSP
HIRED
PHYSICAL
DAMAGE
STATES # DAYS # VEH
COVERAGE IS: PRIMARY SECONDARY
OTHER
49
48
$COLLISION
49
48
CAUSES OF LOSS
SPECIFIED
49
48
OTHER THAN
COLLISION
ZONE
DEDUCTIBLERADIUS# DAYS
FARTH
# TRAILERSSYMBOLCOVERAGES
TRAILER INTERCHANGE
HIRED / BORROWED
NON-TRUCKERS
$
IF ANY BASISCOST OF HIRE
STATESYES
NO
(50) NON-OWNED AUTOS ONLY
INTERCHANGE AGREEMENT
ANOTHER TRUCKER UNDER A TRAILER
(49) YOUR TRAILERS IN THE POSSESSION OF
A TRAILER INTERCHANGE AGREEMENT
(48) TRAILERS IN YOUR POSSESSION UNDER
(47) HIRED AUTOS ONLY
(46) SPECIFICALLY DESCRIBED AUTOS
MOTORIST LAW
COMPULSORY UNINSURED
(45) OWNED AUTOS SUBJECT TO A
(44) OWNED AUTOS SUBJECT TO NO-FAULT
(43) OWNED COMMERCIAL AUTOS ONLY
(42) OWNED AUTOS ONLY
(41) ANY AUTO
COVERED AUTO SYMBOLS
TRUCKERS SECTION
LIMITSCOVERED AUTO SYMBOLSCOVERAGES
50
47
46
43
42
41
LIABILITY
CSL
BI
EA PER
BI EACH ACCIDENT
PROPERTY DAMAGE
$
$
$
PHYSICAL DAMAGE
DEDUCTIBLELIMITS
AUTO SYMBOLS
COVERED
COVERAGES
46
45
43
42
MOTORIST
UNDERINSURED
UNINSURED /
$
$
$
PROPERTY DAMAGE
BI EACH ACCIDENT
EA PER
BI
CSL
NUMBER OF RELATIVES:EXTRA PIP OPTIONS
$
IF ANY BASISCOST OF HIRE
TRUCKERS
HIRED / BORROWED
LIABILITY
NO
YES STATES
LIABILITY
AUTO
NON-OWNED
GROUP TYPE
EMPLOYEES
VOLUNTEERS
PARTNERS
NUMBER OF
NO
YES STATES
$
$
$
DED
MEDICAL EXPENSE
NO THRESHOLD
MEDICAL ONLYLAWSUIT THRESHOLD
NOYESHEALTH INSURANCE OPTION
EXT MED EXP EA PER
PERSONAL
INJURY
PROTECTION
44
46
ENDORSEMENTS / REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
SIGNATURE
APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE
COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT RENEWALS. SUCH INFORMATION
AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD
PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF
ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST.
CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL
PENALTIES.
I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTURE POLICY
RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING.
Page 3 of 3
AGENCY CUSTOMER ID:
HIRED
PHYSICAL
DAMAGE
STATES # DAYS # VEH
COVERAGE IS: PRIMARY SECONDARY
NUMBER OF RELATIVES:EXTRA PIP OPTIONS
69
70
$COLLISION
69
70
CAUSES OF LOSS
SPECIFIED
DEDUCTIBLERADIUS# DAYSSTATE# TRAILERSSYMBOLCOVERAGES
TRAILER INTERCHANGE
67
66
64
63
62
UNINSURED /
UNDERINSURED
MOTORIST
$
$
$
PROPERTY DAMAGE
BI EACH ACCIDENT
EA PER
BI
CSL
$
63
67
& LABOR
TOWING
$68
67
64
63
62
COLLISION
DEDUCTIBLELIMITS
AUTO SYMBOLS
COVERED
COVERAGES
PHYSICAL DAMAGE
$
$
$
PROPERTY DAMAGE
BI EACH ACCIDENT
EA PER
BI
CSL
71
68
67
64
63
62
61
LIABILITY
LIMITSCOVERED AUTO SYMBOLSCOVERAGES
MOTOR CARRIER SECTION
(65) OWNED AUTOS SUBJECT TO NO-FAULT
(71) NON-OWNED AUTOS ONLY
INTERCHANGE AGREEMENT
ANOTHER TRUCKER UNDER A TRAILER
(70) YOUR TRAILERS IN THE POSSESSION OF
A TRAILER INTERCHANGE AGREEMENT
(69) TRAILERS IN YOUR POSSESSION UNDER
(68) HIRED AUTOS ONLY
(67) SPECIFICALLY DESCRIBED AUTOS
SORY UNINSURED MOTORIST LAW
(66) OWNED AUTOS SUBJECT TO A COMPUL-
(64) OWNED COMMERCIAL AUTOS ONLY
(63) OWNED PRIVATE PASS AUTOS ONLY
(62) OWNED AUTOS ONLY
(61) ANY AUTO
COVERED AUTO SYMBOLS
OTHEROTHER
$
IF ANY BASISCOST OF HIRE
NON-TRUCKERS
HIRED / BORROWED
NO
YES STATES
$
IF ANY BASISCOST OF HIRE
TRUCKERS
HIRED / BORROWED
LIABILITY
NO
YES STATES
NON-OWNED
AUTO
LIABILITY
GROUP TYPE
EMPLOYEES
VOLUNTEERS
PARTNERS
NUMBER OF
NO
YES STATES
LSP
FTW
FT
F
SCL
$68
67
64
63
62
CAUSES OF LOSS
SPECIFIED
68
67
64
63
62
$
OTHER THAN
COLLISON
69
70
OTHER THAN
COLLISON
$
$
$
DED
MEDICAL EXPENSE
NO THRESHOLD
MEDICAL ONLYLAWSUIT THRESHOLD
NOYESHEALTH INSURANCE OPTION
EXT MED EXP EA PER
PERSONAL
INJURY
PROTECTION
65
67
ACORD 137 NJ (2008/08)
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Form 5: NEW JERSEY COMMERCIAL AUTO (First Choice Insurance Intermediaries)

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Completed 19 November 2021

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