COMPANY INFORMATION SHEET

 

COMPANY INFORMATION:

Company Name (MUST MATCH INSURANCE) ___________________________

     DBA_____________________________________________________________

Physical Address________________________________________________

     City__________________ State____ Zip________ County_____________

Mailing Address_________________________________________________

     City__________________ State____ Zip________ County_____________

DOT Number (if any) ___________________

Federal ID Number (tax number with IRS) ________________________

Telephone #'s:   Business (____) ____-______ Fax (___) ____-____

     Home (___) ____-______ Other (____) ____-______   Ext: _________

How long have you been in business?   _______Years _______Months

What is the name of your Process Agent Company? ________________

    ________________________________________________________________

 

QUESTIONS:

Do you want your applications sent overnight?  _______Yes _____No

     If yes, we will use our Account # and bill you back for them!!

How many sets of permits (# of trucks) do you want? _____________

Do you want us to process your Fuel Tax reports?  _____Yes ____No

 

TYPE OF OWNERSHIP:

             Individual____    Partnership____   Corporation____

 

If Individual:       Full legal name!

     First_______________ Middle_______________ Last__________________

     Date of birth ____/____/____ Social Security #_____-_____-_______

 

If Partnership:    List all partners names & SS #'s below!

     First_______________ Last___________________ SS#_____-_____-_____

     First_______________ Last___________________ SS#_____-_____-_____

     First_______________ Last___________________ SS#_____-_____-_____

 

If Corporation:      List officers names & SS #'s below!

     President__________________________________ SS#_____-_____-_____

     Vice President_____________________________ SS#_____-_____-_____

     Secretary__________________________________ SS#_____-_____-_____

     Date of Incorporation ____/____/____ Corporation #______________

     State of Incorporation ___________________

 

TYPE OF COMPANY:    (check one or more of the following)

Private (hauls OWN commodities)_________ FHWA Exempt _______

FHWA Common______   FHWA Contract_______  

     If you have FHWA authority, what is your FHWA MC #__________________

     Will you be hauling hazardous materials ____________________________

INSURANCE INFORMATION:

Agents Name_____________________ Phone (____) _____-______ Ext___

Name of Ins. company______________________________________

 

Signature_____________________________ Date____/____/____

Contact person with YOUR company__________________________________