Form T - Certifcate Of Insurance - Montana Public Service Commission printable pdf download

Form T - Certifcate Of Insurance - Montana Public Service Commission

FORM T

BODILY INJURY AND PROPERTY DAMAGE LIABILITY CERTIFICATE OF

INSURANCE FOR TRANSPORTATION NETWORK CARRIERS (TNCs)

Filed with MONTANA PUBLIC SERVICE COMMISSION (hereinafter called Commission)

This is to certify that ____________________________________________ (hereinafter called

(insurance company name)

Company) of ______________________________________________________ has issued to

(insurance company address, city, zip)

_______________________________________ of ________________________________

(TNC name)

(TNC address, city, zip)

_________________________________ a policy or policies of insurance effective from

_______________________ 12:01 A.M. standard time at the address of the insured stated in said

(Date)

policy or policies and continuing until canceled as provided herein, which, by attachment of the

Casualty Insurance Endorsement MV-TNC, has or have been amended to provide automobile

bodily injury and property damage liability insurance covering the obligations imposed upon

such TNC by the provisions of Title 69, Chapter 12, Section 4, Montana Code Annotated and the

regulations promulgated in accordance therewith. 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 Commission, 1701 Prospect Ave., PO Box 202601, Helena, Montana 59620-2601,

said thirty (30) days notice to commence to run from the date notice is actually received in the

office of the Commission.

Filed with the Montana Public Service Commission on _____________________________.

(Date)

Insurance Company File/Policy Number(s): _____________________

(Policy Number)

Authorized Company Representative: __________________________________

(Print name of representative)

___________________________________

(Signature of representative)

Form T - Certifcate Of Insurance - Montana Public Service Commission