CARRIER INTAKE INFORMATION

PLEASE FILL OUT FORM COMPLETELY WITH ACCURATE AND UP-TO-DATE INFORMATION ONCE RECIEVED WE WILL REVIEW. THEN AN ACCOUNT MANAGER WILL CONTACT YOU WITHIN 24-48 HOURS

First Name *

Last Name *

Phone *

Email *

Company Name

Do You Have an Active Authority? *

YES

NO

MC #

US DOT#

Business Address

Address

City

State/Region/Province

Postal / Zip code

Country

Country

Verifiable Authority Start Date

Equipment Type *

Box Truck
Semi
Heavy Haul
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List is empty.

Tractor Info

Make / Model

Trac #1
Trac #2
Trac #3

Year/Home Base Location

-
-
-

Trailer Info

Year

Trailer-1
Trailer-2
Trailer-3

Equipment Type

-
-
-

# of trucks in fleet?

Preferred Regions *

-Select-

New England
Great Lakes
Mid West
North West
South
South East
South West
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Current Insurance Provider

Policy Number

Coverage Amount

Attach copy of authority, COI, Signed W9 & Cab Card (Not Required)

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