Wyoming Administrative Code › Agency 045 - Transportation, Dept. of › Sub-Agency 0004 - Motor Carrier › Chapter 3 - INSURANCE REQUIREMENTS › Section 3-14 - Examples of Filings

Current through July 13, 2024
WYOMING
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
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) __________________
FORM G
UNIFORM MOTOR CARRIER BODILY INJURY AND
PROPERTY DAMAGE LIABILITY SURETY BOND
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
_____________________________
FORM H
UNIFORM MOTOR CARRIER CARGO
CERTIFICATE OF INSURANCE
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) ________________________
FORM J UNIFORM MOTOR CARRIER CARGO SURETY BOND
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)
				  ____________________________
FORM K
UNIFORM NOTICE OF CANCELLATION OF
MOTOR CARRIER INSURANCE POLICIES
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) ________________________
FORM L
UNIFORM NOTICE OF CANCELLATION OF
MOTOR CARRIER SURETY BONDS
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)
________________________