RMX Global Logistics


New Carrier Sign-Up Form

Company Name: *
DBA
Physical Address: *
Remit Address Address: *
City: *
State: *
Nine Digit Zip Code: *
Telephone Number: *
Additional Telephone Number(if have one):
Toll Free Number:
Fax Number: *
Email: *
Website Address:
Emergency Day Number:
Emergency Night Number:
Dispatch Contact: *
Operations Manager: *
Broker Authority: *   Yes   No
Company Type: *   Individual   Corporation   Partnership   LLC
Federal ID#: *
ICC/MC#: *
SCAC Code:
Are you CTPAT certified: *
   Yes   No
Authority: *   Common   Contract   Exempt
Number of Trucks: *   Owned   Leased
Number of Trailers: *   Reefers  Dry Vans   Flatbeds
Reefer Trailer Lengths: *   45'   48'   53'   57'
Van Trailer Lengths: *   45'   48'   53'   57'
Number of Terminal Locations:
Communication Type:   Satellite (GPS)   Cell Phone   Pager

Insurance
Cargo
  Yes
  No
Insurance Carrier: *
Insurance Agent: *
Insurance Phone: *
Policy Number: *
Insurance Contact:
Expiration Date:
Certificate Requested:   Yes   No
Insurance Amount:
Insurance Deductible:
Refrigerator Mechanical Breakdown (if applicable):
General Liability   Yes   No
Insurance Carrier:
Insurance Agent
Insurance Phone:
Policy Number:
Insurance Contact:
Expiration Date:
Certificate Requested:   Yes   No
Insurance Amount:
Insurance Deductible:
Auto Liability   Yes   No
Insurance Carrier: *
Insurance Agent: *
Insurance Phone: *
Policy Number: *
Insurance Contact:
Expiration Date:
Certificate Requested:   Yes   No
Insurance Amount:
Insurance Deductible:
Workman's Compensation   Yes   No
Insurance Carrier: *
Insurance Agent: *
Insurance Phone: *
Policy Number: *
Insurance Contact:
Expiration Date:
Certificate Requested:   Yes   No
Insurance Amount:
Hauling References - Companies you've hauled for (MUST BE COMPLETED)
Company Name: *
Contact: *
Phone: *
Fax: *
Company Name: *
Contact: *
Phone: *
Fax: *
Company Name: *
Contact: *
Phone: *
Fax: *