Dmv 65 Mcp PDF Details

The DMV 65 MCP form, a critical document within the motor carrier industry, serves as a Certificate of Insurance for Motor Carriers of Property in California. It's an assertion from the insurer, detailing coverage for the motor carrier against liabilities involving bodily injury, death, property damage, and workers’ compensation, all within the parameters mandated by California Vehicle Code and federal regulations. This form encapsulates information such as the motor carrier and insurer details, policy numbers, coverage limits, types of insurance, and the effective dates of the policy. It further underscores the insurance company's commitment, by stating that the policy covers all vehicles used by the motor carrier, irrespective of whether they are explicitly listed in the policy. Additionally, it provides for specialized situations like Charitable Risk Pool and Risk Retention Group coverage, aligning with specific legal requirements. By signing the DMV 65 MCP form, insurers not only confirm the accuracy of the provided information under penalty of perjury but also agree to a notification procedure for policy cancellation that protects the interests of the Department of Motor Vehicles and the public at large. Thus, this form plays a pivotal role in ensuring that motor carriers of property operate within the legal safety and financial liability frameworks established by both state and federal directives.

QuestionAnswer
Form NameDmv 65 Mcp
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdmv 65 mcp certificate, dmv65mcp, ca form dmv mcp, how to dmv 65

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DATE RECEIVED BY DMV

CERTIFICATE OF INSURANCE

Motor Carriers of Property

MOTOR CARRIER (CA) #

INSURER (INSURANCE COMPANY) NAME AND ADDRESS

NAIC #

 

Status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensed to write insurance in the State of California

 

 

SURPLUS LINE BROKER #

 

 

(Admitted Insurer)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nonadmitted Insurer subject to Section 1763 of the

 

 

OTHER #

 

 

 

 

California Insurance Code. ______________________

 

 

 

 

 

 

 

 

 

 

Charitable Risk Pool

SURPLUS LINE BROKER NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risk Retention Group

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURED (MOTOR CARRIER) NAME AND ADDRESS

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF INSURANCE

POLICY NUMBER

 

POLICY EFFECTIVE

 

 

LIMITS

 

DATE (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRIMARY LIABILITY

 

 

 

 

 

COMBINED SINGLE LIMIT

 

$

 

 

 

 

 

 

 

 

 

 

Coverage below statutory minimum

 

 

 

 

 

BODILY INJURY OR DEATH

 

$

limits.

 

 

 

 

 

(ONE PERSON)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BODILY INJURY OR DEATH

 

$

Coverage equal to or exceeding

 

 

 

 

 

(MORE THAN ONE PERSON)

 

 

 

 

 

 

 

 

statutory minimum limits.

 

 

 

 

 

PROPERTY DAMAGE

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMBINED SINGLE

 

 

 

EXCESS LIABILITY

 

 

 

 

 

LIMIT

 

$ _______ in excess of $ _____________

 

 

 

 

 

 

 

 

 

 

Coverage between primary cover-

 

 

 

 

 

BODILY INJURY

 

 

 

 

 

 

 

 

(ONE PERSON)

$ _______ in excess of $ _____________

age and statutory minimum limits.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BODILY INJURY OR

 

 

 

Coverage provided at or above

 

 

 

 

 

DEATH (MORE THAN

$ _______ in excess of $ _____________

statutory minimum limits.

 

 

 

 

 

ONE PERSON)

 

 

 

 

 

 

 

 

 

PROPERTY DAMAGE

$ _______ in excess of $ _____________

 

 

 

 

 

 

 

 

 

 

WORKERS’ COMPENSATION

 

 

 

 

 

WC Statutory Limits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

PRINTED NAME OF INSURER’S AUTHORIZED REPRESENTATIVE

 

 

 

TELEPHONE NUMBER

EMAIL ADDRESS

 

 

(

)

 

 

 

 

 

 

 

 

 

SIGNATURE OF INSURER’S AUTHORIZED REPRESENTATIVE

 

 

 

EXECUTED AT (CITY AND STATE)

DATE

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DMV 65 MCP (REV. 2/2005)

 

 

 

 

 

 

 

Clear Form

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