UIIA Electronic Insurance Filing Registration Form

An Account number and Pin number are needed to use the Electronic Insurance Filing option for submittal of insurance information on behalf of UIIA Motor Carriers.   To obtain the Account number and Pin number you need to register with the UIIA as an electronic filer and be an authorized representative of an insurance agency or insurance company.

Registered electronic filers may file certificates, cancellations, reinstatements, additional insured information, view all their online filings, and print their confirmation, acceptance, and reject reports.

Complete the form below and click the "Generate Form" button. It will generate a printable completed form that you must sign and then fax back to us at (301) 982-3414.

You will be provided with an Account Number and Pin Number that will be utilized as your electronic signature each time you provide insurance information online.

The Pin Number will be tied to your signature provided on the registration form below and the registration form containing the actual signature will become part of the certificate should we need to reproduce the Acord certificate for verification of coverage for your insured.

Confirmation of your ability to provide insurance information electronically on behalf of UIIA Motor Carriers will be provided to you via e-mail once the faxed signed copy of this form is received by IANA.

Please mail the completed signed original of the form to:

Intermodal Association of North America (IANA)
c/o UIIA – Electronic Insurance Registration
11785 Beltsville Drive, Suite 1100
Calverton, MD 20705

Insurance Company/Agency Information

* All fields must be filled in.

I certify that I am an authorized representative of the insurance company/insurance agency indicated above and that I am authorized to issue certificates of insurance on behalf of the insurance company(ies) that I identify when providing insurance information on-line.  I certify that the insurance I provide on-line is accurate and in force.  I agree to provide updates to the insurance information provided, should any information change during the insurance policy period and ensure that the information is accurate and up to date at all times.

I further agree that should this agency no longer represent an insured where our agency had provided insurance electronically on behalf of, our company will provide notification of this termination of coverage to IANA within 48 hours of the change.

Authorized Representative Information

Name of Authorized Representative who will be submitting
UIIA insurance information online: