Employer Panel | drsharaf

COMPANY

D/B/A (IF Any)

PHYSICAL ADDRESS (MAILING ADDRESS)

Address

City

ZIP/Postal Code

State/Province

Country

MAIN CONTACT: *

First

Last

OFFICE PHONE

FAX

CELL

EMERGENCY CONTACT *

First

Last

EMERGENCY CONTACT PHONE

Email *

WEBSITE (IF ANY)

DOT#

MC#

SSN/EIN#

SCACCODE

TWIG CERTIFIED

YES
NO

HAZ MAT CERTIFIED

YES
NO

PART 2: EQUIPMENT SECTION

(For more than one truck use the multiple truck form)

PADS

MAX LOAD WEIGHT

COMMENTS

Carrier Profile

REEFER EQUIPMENT

48' REF

53'REF

AIRRIDE

PALLETS

ETRACK

LOAD BARS

FLATBED/SPECIALIZED EQUIPMENT

45' FLAT

48' REF

53' REF

48' STEP DECK

53' STEP DECK

RGN

IF SO SIZE

RAMPS

LEVELERS

CHAINS

STRAPS

EXTRA FLATBED EQUIPMENT

TARPS
SIDES

OVERSIZE

MAX LOAD WEIGHT

COMMENTS

PART 3: SERVICE AREAS OF OPERATION

(Check all that apply)

Mexico

MX

Rate of Haul Information:

Please give us your minimum rate information. We understand that many factors will change this information. But this will give us a starting point.

MINUMUM RATE PER MILE:

MAX PICKS:

MAX DROPS:

COST PER EXTRA STOP:

DRIVER TOUCH:

Yes
No

COMMENTS:

PART 4: FACTORING INFORMATION

If you use a factoring service, please provide us the following information. This will ensure that we only use brokers that are approved by your factoring company.

FACTORING COMPANY NAME

PHONE

FAX

WEBSITE

CONTACT *

First

Last

BILLING ADDRESS

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PART 5: INSURANCE INFORMATION

Please note: We do require our carriers to maintain a minimum of $1 Million in liability and $100,000.00 in Cargo insurance.

INSURANCE COMPANY

CONTACT *

First

Last

Phone

FAX

BILLING ADDRESS (Inusurance)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

OTHER INFORMATION

PLEASE USE THE FOLLOWING SECTION TO BETTER DESCRIBE YOUR COMPANY THAT WE HAVE NOT ALREADY ASKED (For Office Use Only)

MULTIPLE TRUCK OPERATION FORM

Please complete this form if you are a trucking company with more than one (1) truck working under your authority.

TRUCK# (1)

TRAILER# (1)

TYPE TRLR (1)

MAX WGHT (1)

DRIVER (1)

CELL (1)

TRUCK# (2)

TRAILER# (2)

TYPE TRLR (2)

MAX WGHT (2)

DRIVER (2)

CELL (2)

TRUCK# (3)

TRAILER# (3)

TYPE TRLR (3)

MAX WGHT (3)

DRIVER (3)

CELL (3)

Employer Dashboard

PHYSICAL ADDRESS (MAILING ADDRESS)

PART 2: EQUIPMENT SECTION

Carrier Profile

FLATBED/SPECIALIZED EQUIPMENT

PART 3: SERVICE AREAS OF OPERATION

Rate of Haul Information:

PART 4: FACTORING INFORMATION

PART 5: INSURANCE INFORMATION

MULTIPLE TRUCK OPERATION FORM