
Insurer certifies to each of the following:
that the motor carrier of property (Insured) identified herein is covered by an insurance policy providing bodily injury or death
liability, property damage liability insurance, or workers compensation insurance within the coverage limits identified above as
required by California Vehicle Code (CVC) Section 34630, 34631.5, and 34640, and by Part 387 of Title 49 of the Code of
Federal Regulations.
that this insurance policy covers all vehicles used in conducting the service performed by the Insured for which a motor carrier
permit is required whether or not said vehicle is listed in the insurance policy.
that a fully executed Endorsement, on a form authorized by the Department of Motor Vehicles (DMV), is attached to the referenced
policy to conform to the requirements of the Motor Carriers of Property Permit Act, CVC Section 34600 and following, and the
rules and regulations of the DMV. (This provision does not apply to Workers Compensation Insurance.)
that for the purposes of Charitable Risk Pool coverage, this policy meets the requirements of the CVC Section 34631 (d).
that for the purposes of Risk Retention Group coverage, this policy meets the requirements of the Risk Retention Act of 1991,
California Insurance Code Section 125 and following, and is authorized to do business in California.
Insurer agrees to each of the following:
that this Certificate of Insurance shall not be canceled on less than thirty (30) days notice from the Insurer to the DMV and written
on a Notice of Cancellation form authorized by the DMV, and that the thirty (30) day period commences to run from the date the
Notice of Cancellation form was actually received at the office of the California Department of Motor Vehicles, Motor Carrier
Services Branch, in Sacramento, California.
that a duplicate original of the referenced policy, a DMV authorized endorsement, and all other related endorsements and
documentation, shall be furnished to DMV upon request.
By signing this form, the Insurer certifies under penalty of perjury under the laws of the State of California that all information
contained in this Certificate of Insurance is true and correct.
COMBINED SINGLE LIMIT $
BODILY INJURY OR DEATH
$
(ONE PERSON)
BODILY INJURY OR DEATH
$
(MORE THAN ONE PERSON)
PROPERTY DAMAGE $
COMBINED SINGLE
LIMIT $ _______ in excess of $ _____________
BODILY INJURY
(ONE PERSON) $ _______ in excess of $ _____________
BODILY INJURY OR
DEATH (MORE THAN $ _______ in excess of $ _____________
ONE PERSON)
PROPERTY DAMAGE $ _______ in excess of $ _____________
WC Statutory Limits
CERTIFICATE OF INSURANCE
Motor Carriers of Property
DMV 65 MCP (REV. 2/2005)
PRIMARY LIABILITY
Coverage below statutory minimum
limits.
Coverage equal to or exceeding
statutory minimum limits.
EXCESS LIABILITY
Coverage between primary cover-
age and statutory minimum limits.
Coverage provided at or above
statutory minimum limits.
WORKERS’ COMPENSATION
TYPE OF INSURANCE POLICY NUMBER
POLICY EFFECTIVE
LIMITS
DATE (MM/DD/YY)
INSURER (INSURANCE COMPANY) NAME AND ADDRESS
INSURED (MOTOR CARRIER) NAME AND ADDRESS
Status:
Licensed to write insurance in the State of California
(Admitted Insurer)
Nonadmitted Insurer subject to Section 1763 of the
California Insurance Code. ______________________
Charitable Risk Pool
Risk Retention Group
Filed with the: California Department of Motor Vehicles
Motor Carrier Services Branch
P. O. Box 932370 MS G875
Sacramento, CA 94232-3700
(916) 657-8153
PRINTED NAME OF INSURERS AUTHORIZED REPRESENTATIVE TELEPHONE NUMBER EMAIL ADDRESS
SIGNATURE OF INSURERS AUTHORIZED REPRESENTATIVE EXECUTED AT (CITY AND STATE) DATE
X
MOTOR CARRIER (CA) #DATE RECEIVED BY DMV
NAIC #
SURPLUS LINE BROKER #
OTHER #
SURPLUS LINE BROKER NAME
( )