NEW CARRIER SIGN UP REQUEST FORM

Transcription

1 Instructions: (Please fax or the completed documents) Fax: o Fill o Copy o Copy o initial o Insurance out Carrier profile of Common Carrier Authority Company name must match the name on the certificate of insurance. of Carrier s Hazmat Transportation Authority (if Applicable) every page and sign last page of the broker/carrier Contract Certificate (See Request for proper insurance) $250,000 Cargo Liability (Required) $1,000,000 Auto Liability (Required) $1,000,000 General Liability (Required) $100,000 Loss or damage to Non Owned Liability (Required) Must show TransX Ltd as ADDITIONAL INSURED o Completed TransX LTD 2595 Inkster Blvd. Winnipeg, Manitoba R3C 2E6, Canada W-9 or W-8 form (US Carriers only) Initials 1 P a g e

2 NEW CARRIER SIGN UP REQUEST FORM Company Name: Physical Address: Carrier Contact Information Legal Name DBA / Operating Name Street Address Unit # Mailing Address: City State/Province ZIP /Postal Code Country Street Address Unit # City State/Province ZIP /Postal Code Country Work Phone: Fax: Toll Free Number: Emergency Phone Day: Dispatch Phone: Emergency Phone Night: Contact Name: Last Name First Name Company url: Authority Common Contract Exempt C-TPAT Smart Way Authority Numbers: DOT# ICC/MC# SCAC Code SVI# (C-TPAT) D&B# EIN# Initials 2 P a g e

3 Type of Carrier Asset Based Company Type Freight Forwarder Carrier Profile 3PL Individual Corporation Partnership LLC Service Type LTL TL Intermodal Ocean Air Local Regional National International Technology Satellite Tracking Fleet Size Owned / Leased Equipment XML EDI Capability Brokers Teams Online Tracking Reefers Dry Flatbeds Intermodal Reefer Trailers Length Straight Dry Trailers Length Straight (24-32 ) Flat Bed Trailers Length Flatbed Lowboy Drop Deck Double Decker Intermodal Chassis Length Insurance Cargo: Combo Extendable Insurance Carrier Insurance Agent Policy Number Insurance Phone Insurance Contact Certificate Requested Insurance Amount Insurance Deductible Expiration Date General Liability: Insurance Carrier Insurance Agent Policy Number Insurance Phone Insurance Contact Certificate Requested Insurance Amount Insurance Deductible Expiration Date Initials 3 P a g e

4 Reference: Terminal Locations: Initials 4 P a g e

5 DESTINATION Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Teritories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Sweet Spot Service Area TX LOGISTICS ORIGIN AB BC MB NB NL NT NS NU ON PE QC SK YT AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Alberta AB British Columbia BC Manitoba MB New Brunswick NB Newfoundland and Labrador NL Northwest Teritories NT Nova Scotia NS Nunavut NU Ontario ON Prince Edward Island PE Quebec QC Saskatchewan SK Yukon YT Alaska AK Arizona AZ Arkansas AR California CA Colorado CO Connecticut CT Delaware DE Florida FL Georgia GA Hawaii HI Idaho ID Illinois IL Indiana IN Iowa IA Kansas KS Kentucky KY Louisiana LA Maine ME Maryland MD Massachusetts MA Michigan MI Minnesota MN Mississippi MS Missouri MO Montana MT Nebraska NE Nevada NV New Hampshire NH New Jersey NJ New Mexico NM New York NY North Carolina NC North Dakota ND Ohio OH Oklahoma OK Oregon OR Pennsylvania PA Rhode Island RI South Carolina SC South Dakota SD Tennessee TN Texas TX Utah UT Vermont VT Virginia VA Washington WA West Virginia WV Wisconsin WI Wyoming WY