Motor Carrier Forms Bodily Injury and Property Damage Liability

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1 ALPHABETICAL INDEX Forms are listed alphabetically by form title. Important Note: The forms shown herein for each state may not be a complete listing of all the motor carrier bodily injury and property damage liability forms that are required for the state. Some forms are not stocked by WOLTERS KLUWER because of their infrequent use (resulting in little demand) or because supplies are available from a state source. The state usage indicated for the various forms was based on the best information we had at the time of publication. You should be guided by individual state requirements. PAGE MC 1 of 5 WOLTERS KLUWER Customer Support:

2 FEDERAL MOTOR CARRIER ACT (D) MC1661 D 11/11 BOC-3 DESIGNATION OF AGENTS FOR SERVICE OF PROCESS (E) MC1612 G 02/17 MCS-90B FOR MOTOR CARRIER POLICIES OF FOR PUBLIC LIABILITY UNDER SECTION 18 OF THE BUS REGULATIORY REFORM ACT OF 1982 MC1622 S 01/17 MCS-90 FOR MOTOR CARRIER POLICIES OF FOR PUBLIC LIABILITY UNDER SECTIONS 29 AND 30 OF THE MOTOR CARRIER ACT OF 1980 (M) MC1711 E 01/17 MCS-82B MOTOR CARRIER PUBLIC LIABILITY SURETY BOND UNDER SECTION 18 OF THE BUS REGULATORY REFORM ACT OF 1982 MC1662 D 01/17 MCS-82 MOTOR CARRIER PUBLIC LIABILITY SURETY BOND UNDER SECTIONS 29 AND 30 OF THE MOTOR CARRIER ACT OF 1980 NARUC FORMS: UNIFORM MOTOR CARRIER FORMS Developed by National Association of Regulatory and Utility Commissioners (NARUC) for use in states which have adopted the Uniform Motor Carrier Program. When an interstate carrier filing is required, use forms E, F, K, L and G. For intra-state carriers, use special state forms, except where forms E, F, K, L and G are shown for the state. MC2445 (Form K) applies in all states except GA. MC2446 (Form L) applies in all states except MA, MT, and RI. (F) MC1632 A 08/99 IRB3538A FORM F UNIFORM MOTOR CARRIER BODILY INJURY AND PROPERTY DAMAGE LIABILITY (N) MC2445 A 08/99 FORM K NOTICE OF CANCELLATION OF MOTOR CARRIER POLICIES (FORM K) (U) MC1633 A 08/99 FORME/IRB3539B UNIFORM MOTOR CARRIER BODILY AL, AR, AZ, CA, CO, CT,, HI, ID, IL, IN, KS, KY, LA, ME, MI, MN, MO, MT, NC, ND, NE, NH, NM, NV, NY, OH, OK, OR, PA, SC, SD, TN, TX, UT, VA, WA, WI, WV, WY AK, AL, AR, CO, HI, IA, IL, IN, KS, KY, LA, ME, MI, MN, MO, MS, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, RI, SC, SD, TN, TX, UT, VA, WV, WY AK, AL, AR, AZ, CO, CT, DC, DE, FL, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, PAGE MC 2 of 5 WOLTERS KLUWER Customer Support:

3 (FORM E)(USED IN MULTIPLE STATES) MC1690 A 08/99 FORM F UNIFORM MOTOR CARRIER BODILY LIABILITY (FORM F)(2 PART SNAP SET) MC1635 A 08/99 FORM G UNIFORM MOTOR CARRIER BODILY INJURY PROPERTY DAMAGE SURETY BOND (FORM G) MC2446 A 07/99 FORM L UNIFORM NOTICE OF CANCELLATION OF MOTOR CARRIER SURETY BONDS (FORM L) GENERAL USE/STATE SPECIFIC Alaska MC1664 B 11/99 DOT UNIFORM NOTICE OF CANCELLATION OF MOTOR CARRIER POLICIES Arkansas MC /71 IRB2831A CERTIFICATE (TAXICABS) California MC1730 A 08/02 DMV55MCPREV802 CALIFORNIA MOTOR CARRIER LIABILITY SURETY BOND MC2404 J 11/10 MC 65 M MC1617 A 07/02 DTSC FOR PUBLIC LIABILITY COVERAGE MC1644 A 11/99 PL912REV1289 (CLASS C CHARTER- PARTY CARRIERS) MC /99 TL1009 (FOR USE WITH PRIVATE CARRIERS/YOUTH CAMPS) MC1682 D 11/99 TL675AREV0781 (PROPERTY CARRIERS) MC2406 F 10/10 MC 67 M POLICY - CALIFORNIA MC1680 B TL568 NOTICE OF CANCELLATION MC1646 A 11/99 PL NOTICE OF CANCELLATION (APPLIES TO PASSENGER STATE CORPORATION AND/OR CHARTER-PARTY CARRIER OF PASSENGERS) MC1626 A 05/99 TL 1002 NOTICE OF CANCELLATION (FOR USE WITH PRIVATE CARRIERS) MC2405 E 09/10 MC 66 M NOTICE OF CANCELLATION OF MC1624 B 11/99 TL944 NOTICE OF CANCELLATION OF WORKERS' COMPENSATION Colorado MC /99 FORM 14-INS GARAGE KEEPERS LEGAL LIABILITY MC /99 PUC FORM 10-INS NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, AL, AR, AZ, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, SC, SD, TN, AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY PAGE MC 3 of 5 WOLTERS KLUWER Customer Support:

4 TOWING CARRIER PUBLIC LIABILITY AND PROPERTY DAMAGE CERTIFICATE Connecticut MC1641 B 12/99 IRB3614B CERTIFICATE (PUBLIC SERVICES, SCHOOL BUS AND SERVICES BUS)(NOT AVAILABLE ELECTRONICALLY) GU1327 G 07/09 IRB 3616D SPECIAL NOTICE OF CANCELLATION OR TERMINATION (NOT AVAILABLE ELECTRONICALLY) Georgia MC1726 B 07/14 GA FORM E UNIFORM MOTOR CARRIER BODILY (FORM E) MC1728 B 07/14 GA FORM K UNIFORM NOTICE OF CANCELLATION OF MOTOR CARRIER POLICIES (FORM K) Indiana MC /86 FORM E - IN MC /71 IRB3272A NOTICE OF REINSTATEMENT Kentucky MC1621 A 11/99 MOTOR VEHICLE DEALER BI/PD MC /88 UNIFORM MOTOR CARRIER BI/PD Maine MC1722 H 02/17 FORM JB MV214 STATE OF MAINE - CERTIFICATE FOR HIRE PASSENGER VEHICLE Michigan MC /97 MDOT 3007 BUS MC /98 MDOT 3046 LIMOUSINE CARRIERS MC1724 A 11/04 MDOT 3003 NOTICE OF CANCELLATION OF MC /95 PR PUBLIC LIABILITY HAZARDOUS WASTE TRANSPORTER- LIABILITY AMENDATORY MC /95 PR PUBLIC LIABILITY LIQUID INDUSTRIAL WASTE TRANSPORTER LIABILITY AMENDATORY Minnesota MC /04 COMMERCIAL VEHICLE CERTIFICATE OF BODILY INJURY/ PROPERTY DAMAGE LIABILITY FOR USE WITH THE METRO AIRPORTS COMMISSION MC /02 EVIDENCE OF WORKER'S COMPENSATION Montana MC1678 D 05/15 MV-4 CASUALTY MC1740 A 10/09 HQ MV-5C CERTIFICATE OF CANCELLATION - MONTANA INTRASTATE COMMERCIAL TOW TRUCK OPERATIONS MC /10 HQ MV-5 PAGE MC 4 of 5 WOLTERS KLUWER Customer Support:

5 - MONTANA INTRASTATE COMMERCIAL TOW TRUCK OPERATIONS Ohio MC /98 BOND COVERING ANY AND ALL PERMITS ISSUED TO PRINCIPAL FOR MOVEMENTS OF EXCESS LOADS OVER STATE HIGHWAYS MC1670 B 10/08 OS TO LIABILITY POLICY FOR VEHICLES OPERATING WITH A SPECIAL HAULING PERMIT ISSUED BY THE OHIO DEPARTMENT OF TRANSPORTATION MC /71 I25B POLICY CERTIFICATE (LEASED EQUIPMENT) Texas MC1628 C 06/10 FORM 1902 COMMERCIAL MOTOR VEHICLE BODILY MC1652 B 11/99 FORM1896T0895 GARAGE KEEPERS LEGAL LIABILITY West Virginia MC1604 E 09/10 DMV-126-DS-J DEALER VEHICLE LIABILITY AND PROPERTY DAMAGE CERTIFICATE OF MC /03 MV126DSKREV394 NOTICE OF CANCELLATION VEHICLE DEALER LIABILITY POLICIES Wisconsin MC1615 B 10/99 S-2 AMENDED SCHEDULE OF VEHICLES MC1610 B 10/99 B-1 (BLANKET) MC1613 B 10/99 FORM S-1 (SCHEDULE) MC1620 A 09/99 FORM FX MC /85 FORMEX MOTOR CARRIER LIABILITY PAGE MC 5 of 5 WOLTERS KLUWER Customer Support: