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