PUC/ICC FILING REQUEST [Complete a Filing Request form for every filing/name] Standard Request URGENT REQUEST [Needed same day or in 24 hours] POLICY NAME: POLICY # CURRENT POLICY # CARRIER: ENIC (Everest) INSURED ADDRESS AS SHOWN ON POLICY: EFFECTIVE DATE: [Cannot use a date prior to policy effective date] NOTES/REMARKS: FILING REQUIREMENTS NEW AMEND REINSTATE CANCEL NAME AS IT IS TO APPEAR ON FILING: ADDRESS AS IT IS TO APPEAR ON FILING PUC FORM E/H STATES: BI/PD CARGO CA T# (FOR CA DMV) ICC: BI/PD CARGO USDOT/FHWA: MC# or DOT # LIMIT [State requirement, not the policy limits]: $750,000 $1,000,000 OTHER $ GL COLORADO TEXAS CERTIFICATE # CERTIFICATE OF WAREHOUSE LEGAL LIABILITY: (RSMO) ZONE CA (WA, OR, CA, ID, NV, UT, AZ, NM) GA (KY, TN, NC, SC, GA, AL, MS, FL) KS (MT, WY, CO, ND, SD, NE, KS, OK, TX, LA, AR, MO, AK) NJ (MN, IA, IL, IN, MI, WI, OH, PA, NY, NJ, CT, VA, DE, MA, NH, ME, MD, RI, DC, VT, WV) ADDRESS OF WAREHOUSE Limit of Liability $ ADDRESS OF WAREHOUSE Limit of Liability $ ADDRESS OF WAREHOUSE Limit of Liability $ ATLAS CERTIFICATE ATLAS UMBRELLA YES NO LIMIT $ ADDL LOC ADDRESS (IF APPLICABLE) ADDL LOC ADDRESS (IF APPLICABLE) ADDL LOC ADDRESS (IF APPLICABLE) CALIFORNIA: CA# TL 676 BI/PD TL 672 CARGO MILITARY ETA/SCAC (MTMC) CODE(S) # OTHER DESCRIBE LIMITS $ $ REQUEST DATE: AGENT: ATTN: FAX#: EMAIL ADDRESS Additional Information: PUC/ICC Filing Request Instructions and Notations (This is a pilot program, subject to change at a later date) 1) For new business, a Filing Request form needs to be completed for every separate filing for which there is a different filing name. It is not necessary to complete a filing form for renewal binds that already have a filing in place. 2) Limits - The Limit options referred to ($750,000 and $1,000,000) pertain to the minimum state filing requirements – they may or may not match to the policy limits. 3) Effective Date – Cannot indicate a date prior to the policy effective date 4) The Filing Request form should be emailed to your underwriter who needs to approve it for processing. 5) Do not send a Filing Request form until you have sent the bind order. 6) For any ICC filing questions, you can refer to the web site for the Federal Motor Carrier Safety Administration (FMCSA) and select the Licensing & Insurance Requirements option: http://www.fmcsa.dot.gov/registration-licensing/licensing/registr.htm 7) For any state filing questions refer to the appropriate state website as an initial resource. 8) Turn-around time – The Standard filing requests are typically processed the same day they are received up to 2:00 PST. After 2:00 PST, they are usually processed the following day. Shortly after processing, you should receive an email confirmation that the filing has been delivered electronically, faxed, or mailed to the ICC or applicable State office. 9) If you have any questions on the completion of this form, please refer to your underwriter. For Urgent Requests, the filing is processed the same day if received prior to 4:00 PST.
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