Wyoming Administrative Code › Agency 045 - Transportation, Dept. of › Sub-Agency 0004 - Motor Carrier › Chapter 3 - INSURANCE REQUIREMENTS › Section 3-17 - Examples of Filings

Current through July 13, 2024
YOMING
FORM MC61E
CONTRACT MOTOR CARRIER
HOUSE TRAILER OR MOBILE HOME
CERTIFICATE OF INSURANCE
Filed With
WYOMING DEPARTMENT OF TRANSPORTATION
REGULATORY SECTION
Cheyenne, Wyoming
THIS IS TO CERTIFY, That the ___________________ (hereinafter
				  called company) of
				  __________________________________________________________________ has issued
				  to ______________________________ of ________________________
(Name of Motor Carrier) (Address of Motor Carrier)
the policy of Insurance herein described has been amended by
				  the attachment of an endorsement, in the amount of $5,000.00 for physical
				  damage coverage for each house trailer or mobile home transported and approved
				  by the Wyoming Department of Transportation to provide compensation for loss of
				  or damage to house trailers or mobile homes belonging to shippers or consignees
				  and coming into the possession of the Insured in connection with its
				  transportation service under a permit issued to the Insured by the Department
				  under Title 31, Wyoming Statutes 1999, as amended, and the pertinent rules and
				  regulations of the Department regardless of whether the house trailers or
				  mobile homes themselves or the motor vehicles, and other facilities used in
				  connection with the transportation of said house trailers or mobile homes are
				  specifically described in the policy or not. 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 within the State
				  of Wyoming.
Whenever requested by the Department, the Company agrees to
				  furnish to the Department a duplicate original of said policy and all
				  endorsements thereon.
The endorsement described herein may not be canceled without
				  cancellation of the policy 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 Department at its office in Cheyenne, Wyoming, said thirty (30)
				  days' notice to commence to run from the date notice is actually received at
				  the office of said Department.
Policy No. _______ Effective from 12:01 A.M. standard time at
				  the address of the Insured stated in said policy or policies and continuing
				  until canceled as provided herein.
Countersigned at ____________________________ this ___ day of
				  __________ , ____.
______________________________
MC 61E Authorized Company Representative
FORM E
UNIFORM MOTOR CARRIER BODILY INJURY AND PROPERTY
DAMAGE LIABILITY CERTIFICATE OF INSURANCE
(Execute in Triplicate)
Filed with _______________________ (hereinafter called
				  Commission)
(Name of Commission)
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 insurance effective from
				  ________________ 12:01 A.M. standard time at the address of the insured stated
				  in said policy or policies and continuing until canceled as provided herein,
				  which, by attachment of the Uniform Motor Carrier Bodily Injury and Property
				  Damage Liability Insurance Endorsement, has or have been amended to provide
				  automobile bodily injury and property damage liability insurance covering the
				  obligations imposed upon such motor carrier by the provisions of the motor
				  carrier law of the State in which the Commission has jurisdiction or
				  regulations promulgated in accordance therewith.
Whenever requested, the Company agrees to furnish the
				  Commission a duplicate original of said policy or policies and all endorsements
				  thereon.
This certificate and the endorsement described herein may not
				  be canceled without cancellation of the policy 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 State Commission, such thirty (30) days' notice
				  to commence to run from the date notice is actually received in the office of
				  the Commission.
Countersigned at
				  ______________________________________________________
(Street Address) (City) (State) (Zip Code)
This _______ day of __________ , ____.
_____________________________
Authorized Company Representative
Insurance Company File No. _____________
(Policy Number) ________________
This form determined by the National Association of
				  Regulatory Utilities Commissioners and promulgated pursuant to the provisions
				  of Section 202(b)(2) of the Interstate Commerce Act (49 U.S.C., Sec.
				  302[b][2]).
FORM G
UNIFORM MOTOR CARRIER BODILY INJURY AND PROPERTY DAMAGE
				  LIABILITY SURETY BOND
(Execute in Triplicate)
KNOW ALL MEN BY THESE PRESENTS, That we,
				  ______________________________
(Name of Motor Carrier Principal)
of ____________ , ______________ as Principal (hereinafter
				  called
(City) (State)
Principal), and
				  __________________________________________________________
(Name of Surety)
a corporation created and existing under the laws of the
				  State of ________ ,
with principal office at _________ , _________________ , as
				  Surety,
(City) (State)
(hereinafter called Surety), are held and firmly bound unto
				  the State of _____________ in the sum or sums hereinafter provided for which
				  payment, well and truly to be made, the Principal and Surety hereby bind
				  themselves, their successors and assigns, firmly by these presents.
THE CONDITION OF THIS OBLIGATION IS SUCH THAT:
WHEREAS, the Principal is or intends to become a motor
				  carrier subject the laws of such State and the rules and regulations of
				  _________________________
Name of Commission (hereinafter called Commission), relating
				  to insurance of other security for the protection of the public, and has
				  elected to file with the Commission a surety bond conditioned as hereinafter
				  set forth, and
WHEREAS, This bond is written to assure compliance by the
				  Principal as a motor carrier of passengers or property with the laws of such
				  State and the rules and regulations of the Commission relating to insurance or
				  other security for the protection of the public, and shall inure to the benefit
				  of any person or persons who shall recover a final judgment or judgments
				  against the Principal for any of the damages herein described.
NOW, THEREFORE, if every final judgment recovered against the
				  Principal for bodily injury to or the death of any person or loss of or damage
				  to the property of others, sustained while this bond is in effect, and
				  resulting from the negligent operation, maintenance, or use of motor vehicles
				  in transportation (but excluding injury to or death of the Principal's
				  employees while engaged in the course of their employment, and loss of or
				  damage to property of the Principal and property transported by the Principal
				  designated as cargo), shall be paid, then this obligation shall be void,
				  otherwise to remain in full force and effect.
Within the limits hereinafter provided, the liability of the
				  Surety extends to such losses, damages, injuries, or deaths regardless of
				  whether such motor vehicles are specifically described herein and whether
				  occurring on the route or in the territory authorized to be served by the
				  Principal or elsewhere.
This bond is effective from ____________ (12:01 A.M.,
				  standard time, at the address of the Principal as stated herein) and shall
				  continue in force until terminated as hereinafter provided. The Principal or
				  the Surety may at any time terminate this bond by written notice to the
				  Commission, such termination to become effective not less than thirty (30) days
				  after actual receipt of said notice by the Commission. The Surety shall not be
				  liable hereunder for the Payment of any judgment or judgments against the
				  Principal for bodily injury to or the death of any person or persons or loss of
				  or damage to property resulting from accidents which occur after the
				  termination of this bond as herein provided, but such termination shall not
				  affect the liability of the Surety hereunder for the Payment of any such
				  judgment or judgments resulting from accidents which occur during the time the
				  bond is in effect.
The liability of the Surety on each motor vehicle shall be
				  the limits prescribed in the laws of such State and the rules and regulations
				  of the Commission governing the filing of surety bonds, which were in effect at
				  the time this bond was executed, and shall be a continuing one notwithstanding
				  any recovery hereunder.
IN WITNESS WHEREOF, the said Principal and Surety have
				  executed this instrument on the ____ day of ____________ , ____.
_______________________________
(Principal)
By _____________________________
(Affix Corporate Seal) (Surety)
_______________________________
(City) (State)
By _____________________________
Countersigned at ____ this ____ day of _____________
				  ____.
Bond No. _______________
				  ________________________________
Registered Resident Agent
__________________________
This form determined by the National Association of
				  Regulatory Utilities Commissioners and promulgated pursuant to the provisions
				  of Section 202(b)(2) of the Interstate Commerce Act (49 U.S.C., Sec.
				  302[b][2]).
FORM H
UNIFORM MOTOR CARRIER CARGO CERTIFICATE OF INSURANCE
(Execute in Triplicate)
Filed with ________________________ (hereinafter called
				  Commission).
(Name of Commission)
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 insurance effective from
				  ______________ 12:01 A.M., standard time at the address of the insured stated
				  in said policy or policies and continuing until canceled as provided herein,
				  which, by attachment of the Uniform Motor Carrier Cargo Insurance Endorsement,
				  has or have been amended to provide cargo insurance covering the obligation
				  imposed upon such motor carrier by the provisions of the motor carrier law of
				  the State in which the Commission has jurisdiction or regulations promulgated
				  in accordance therewith.
Whenever requested, the Company agrees to furnish the
				  Commission a duplicate original of said policy or policies and all endorsements
				  thereon.
This certificate and the endorsement described herein may not
				  be canceled without cancellation of the policy 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 State Commission, such thirty (30) days' notice
				  to commence to run from the date notice is actually received in the office of
				  the Commission.
Countersigned at
				  ________________________________________________________
(Street Address) (City) (State) (Zip Code)
This __________ day of _______________ , ___.
_____________________________
Authorized Company Representative
Insurance Company File No. _______________
(Policy Number) ______________________
This form determined by the National Association of
				  Regulatory Utilities Commissioners and promulgated pursuant to the provisions
				  of Section 202(b)(2) of the Interstate Commerce Act (49 U.S.C., Sec.
				  302[b][2]).
FORM J
UNIFORM MOTOR CARRIER CARGO SURETY BOND
(Execute in Triplicate)
KNOW ALL MEN BY THESE PRESENTS, That we,
				  _____________________________
(Name of Motor Carrier Principal)
of _______________ , _________________ as Principal
				  (hereinafter called Principal),
(City) (State)
and
				  ___________________________________________________________________ (Name of
				  Surety)
a corporation created and existing under the laws of the
				  State of ________ with principal office
at _______________ , __________________ , as Surety
(City) (State)
(hereinafter called Surety), are held and firmly bound unto
				  the State of _______________ in the sum or sums hereinafter provided for which
				  payment, well and truly to be made, the Principal and Surety hereby bind
				  themselves, their successors and assigns, firmly by these presents.
THE CONDITION OF THIS OBLIGATION IS SUCH THAT:
WHEREAS, The Principal is or intends to become a motor
				  carrier subject to the laws of such State and the rules and regulations of the
				  _______________________
(Name of Commission)
(hereinafter called Commission), relating to insurance or
				  other security for the protection of shippers and consignees, and has elected
				  to file with the Commission a bond conditioned as hereinafter set forth;
				  and
WHEREAS, this bond is written to assure compliance by the
				  Principal as a motor carrier with the laws of such State and the rules and
				  regulations of the Commission relating to insurance or other security for the
				  protection of shippers and consignees, and shall inure to the benefit of any
				  and all shippers or consignees to whom the Principal may be held liable for any
				  of the damages herein described.
NOW, THEREFORE, if the Principal shall make compensation to
				  shippers and consignees for all losses or of damages to property belonging to
				  them which shall, while this bond is in effect, come into the possession of the
				  Principal in connection with its transportation service, regardless of whether
				  such losses or damages occur while said property is in a motor vehicle,
				  terminal warehouse, or other place, for which losses or damages the Principal
				  may be held legally liable, then this obligation shall be void, otherwise it
				  shall remain in full force and effect.
The liability of the Surety for the limits hereinafter
				  provided shall be a continuing one notwithstanding any recovery hereunder, and
				  extends to such losses or damages regardless of whether the motor vehicles,
				  terminals, warehouses, and other facilities used in connection with the
				  transportation service of the Principal are specifically described herein or
				  not, and whether occurring on the route or in the territory authorized to be
				  served by the Principal or elsewhere.
The liability of the Surety for any such loss or damage shall
				  be the limits prescribed in the laws of such State and the rules and
				  regulations of the Commission governing the filing of surety bonds, which were
				  in effect at the time this bond was executed, and shall be a continuing one
				  notwithstanding any recovery hereunder.
This bond is effective from ___________________ (12:01 A.M.,
				  standard time, at the address of the Principal as stated herein) and shall
				  continue in force until terminated as hereinafter provided. The Principal or
				  the Surety may at any time terminate this bond by written notice to the
				  Commission, such termination to become effective not less than thirty (30) days
				  after actual receipt of said notice by the Commission.
The Surety shall not be liable hereunder for the payment of
				  any of the losses or damages hereinbefore described which arise on property
				  coming into the possession of the Principal in connection with its
				  transportation service after the termination of this bond as herein provided,
				  but such termination shall not affect the liability of the Surety hereunder for
				  the payment of any such losses or damages arising on property coming into the
				  possession of the Principal in connection with its transportation service prior
				  to the date such termination becomes effective.
IN WITNESS WHEREOF, the said Principal and Surety have
				  executed this instrument on the _____ day of _________________ , ____.
______________________
(Principal)
By ______________________
(Affix Corporate Seal) (Surety)
_______________________
(City) (State)
By ______________________
Countersigned at ______ this _____ day of ___________________
				  , ____.
Bond No.
				  _______________________________________________________________
(Registered Resident Agent) _________________________
This form determined by the National Association of
				  Regulatory Utilities Commissioners and promulgated pursuant to the provisions
				  of Section 202(b)(2) of the Interstate Commerce Act (49 U.S.C., Sec.
				  302[b][2]).
FORM K
UNIFORM NOTICE OF CANCELLATION OF
MOTOR CARRIER INSURANCE POLICIES
(Execute in Triplicate)
Check Type Canceled:
BI and PD _____________
Cargo _______________
Filed with __________________________ (hereinafter called
				  Commission).
(Name of Commission)
This is to advise that under the terms of a policy or
				  policies issued to
				  ____________________________________________________________________
(Name of Motor Carrier)
of
				  ____________________________________________________________________
(Address of Motor Carrier)
by
				  ____________________________________________________________________
(Name of Company)
of
				  ____________________________________________________________________
(Address)
said policy or policies, including any and all endorsements
				  forming a part hereof or certificates issued in connection therewith, is (are)
				  hereby canceled effective as of the ______ day of ______________ , ___, 12:01
				  A.M., standard time at the address of the Insured as stated in said policy or
				  policies provided such date is not less than thirty (30) days after the actual
				  receipt of this notice by the Commission.
_____________________________
Signature of Insurer
Insurance Company File No. ______________
(Policy Number) ______________________
This form determined by the National Association of
				  Regulatory Utilities Commissioners and promulgated pursuant to the provisions
				  of Section 202(b)(2) of the Interstate Commerce Act (49 U.S.C., Sec.
				  302[b][2]).
FORM L UNIFORM NOTICE OF CANCELLATION OF MOTOR CARRIER SURETY
				  BONDS
(Execute in Triplicate)
Check Type Canceled:
BI and PD _____________
Cargo ________________
Filed with __________________________ (hereinafter called
				  Commission).
(Name of Commission)
This is to advise that, under the terms of surety bond(s)
				  executed in
behalf of
(Name of Principal)
of
(Address)
by
(Name of Surety)
of
(Address)
said bond(s), including any and all riders or certificates
				  attached thereto or issued in connection therewith, is (are) hereby canceled
				  effective as of the ______ day of _____________ , ____, 12:01 A.M., standard
				  time, at the address of the Principal as stated in said bond(s) provided such
				  date is not less than thirty (30) days after the actual receipt of this notice
				  by the Commission.
Signature of Principal or Surety
Insurance Company File No. ______________
(Policy Number)
______________________
This form determined by the National Association of
				  Regulatory Utilities Commissioners and promulgated pursuant to the provisions
				  of Section 202(b)(2) of the Interstate Commerce Act (49 U.S.C., Sec.
				  302[b][2]).