Grade A Logistics Application Date:Field is required!Legal Name of CompanyField is required!Registered Trade Name (D.B.A):Field is required!Field is required!Mailing Address:Field is required!CityField is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingField is required!Field is required!Authorized Contact:Field is required!Title:Field is required!Email Address:Field is required!Phone:Field is required!Fill in email to send insurance certificate request to your insurance company:Field is required!Federal Tax ID #:Field is required!MC #:Field is required!US DOT#:Field is required!- select a option -YesNoField is required!Driver informationDriver:Field is required!Truck #:Field is required!Phone #:Field is required!W-9 (must be signed and dated)Upload your documents...Field is required!Operating Authority and DOT CertificateUpload your documents...Field is required!I agree to the Carrier Workers' Compensation Insurance WaiverI agree to the Broker/Contract Carrier ContractI have been given the option to view/print the Grade A Logistics Setup PacketField is required!$100,000 Regular Cargo Insurance Required.$1,000,000 General Liability Required.$1,000,000 Automobile/Public Liability Required.$150,000 Refrigerated Cargo Coverage.Payment delivery method- select a option -EFS Check (Fee: 5% of Invoice)ACH to your Bank Account Next Day (Fee: 3% of invoice)ACH to your Bank Account 30 Days (Free)Field is required!AccountField is required!Account Type:- select a option -SavingsCheckingField is required!Account Number:Field is required!Routing Number:Field is required!Attach a voided check:Upload your documents...Field is required!Select Office:- select a option -Huntingburg, INIndianapolis, INChampaign, INField is required!SignatureField is required!Submitting this form with your electronic signature binds you to the agreements listed aboveSubmit
