Aljex Carrier Import

BASIC INFORMATION

DOT:

MC:

SCAC:

* Company Name:

* Safety Rating:

Legal Name:

Intrastate:

* Address:

* City:

* State:

select

* Zip Code:

* Contact Name:

* Phone:

Fax:

Addtl Phone:

* Email:

Addtl Email:

Agent Name:

PAYEE INFORMATION

Company Name:

* Federal ID / SSN:

* Contact Email for Missing Paperwork:

Do you factor?

select

Is pay to info the same as bill to info?

Quick Pay Option:

select

Do you want to enter ACH information?

select

(US accounts only)

INSURANCE / EQUIP

Cargo Ins Amount:

*

Exp Date:

Open the calendar popup.

*

$100,000 minimum

Auto Liability Ins Amount:

*

Exp Date:

Open the calendar popup.

*

$1,000,000 minimum

Do You Have Trailer Interchange:

select

Do You Have Scheduled Autos:

select

General Liability Ins Amount:

Exp Date:

Open the calendar popup.

Worker's Comp Ins Amount:

Exp Date:

Open the calendar popup.

Reefer Breakdown Insurance:

select

Hazmat Certified:

select

ASSETS
# of Vans:		# of 53s:
# of Flats:		# of Reefers:
# of Teams:		# of Steps:
# of Hot Shots:		# of Curtain Vans:
# of Conestogas:		# of Power Only:
# of Drivers:

NOTE: The Broker Carrier Agreement must be signed, and your W9, Insurance (sample certificate acceptable) and Authority must all be received for your record to be complete. You will receive a decline if items are missing.

W9, Insurance & Authority are one file

*

Electronic Signature:	*
Date / Time:	12/12/2018 7:33:21 AM
IP Address:	54.84.236.168

I understand that typing my name constitutes a legal signature confirming that I acknowledge and agree to the above and that I am an authorized representative of my company