owner-operator
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
MEMBERSHIP APPLICATION<br />
APPLICANT:<br />
MR.<br />
MRS.<br />
MS.<br />
LAST FIRST MIDDLE<br />
ADDRESS:<br />
(PHYSICAL) STREET<br />
APT/STE CITY STATE ZIP<br />
ADDRESS:<br />
(MAILING)<br />
STREET<br />
APT/STE<br />
CITY<br />
STATE<br />
ZIP<br />
PHONE #:<br />
( )<br />
HOME CELL OTHER<br />
PHONE #:<br />
(<br />
)<br />
HOME CELL OTHER<br />
E-MAIL:<br />
@<br />
NO EMAIL<br />
DO YOU OWN YOUR OWN COMPANY?<br />
YES<br />
NO<br />
IF “YES”, ENTER NAME HERE:<br />
I HEREBY APPLY FOR MEMBERSHIP IN THE NATIONAL ASSOCIATION OF INDEPENDENT TRUCKERS, LLC (“NAIT”)<br />
AND AGREE TO PAY MONTHLY MEMBERSHIP DUES DISCLOSED AT www.naitusa.com.<br />
I UNDERSTAND MEMBERSHIP IS NONTRANSFERABLE.<br />
SUBMISSION OF THIS APPLICATION FOR MEMBERSHIP AUTHORIZES NAIT AND ITS AFFILIATED BENEFIT PROVIDERS TO CONTACT ME<br />
OR MY COMPANY BY MAIL, PHONE, FAX OR E-MAIL REGARDING NAIT MEMBERSHIP AND MEMBER BENEFITS.<br />
SIGNATURE:<br />
DATE:<br />
RETURN TO:<br />
MAIL: PO BOX 901606, KANSAS CITY, MO 64190<br />
E-MAIL: MemberBenefits@NAITUSA.com<br />
FAX: (816) 713-1333<br />
018019 3/15<br />
FOR ADDITIONAL INFORMATION ON YOUR TOTAL BENEFIT PACKAGE VISIT www.naitusa.com OR CALL (800) 821-8014<br />
Follow us on Twitter: @naitusa
Motor Vehicles Driver’s<br />
CERTIFICATION OF COMPLIANCE<br />
WITH DRIVER LICENSE REQUIREMENTS<br />
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in<br />
intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport<br />
more than 15 people, or transports hazardous materials that require placarding.<br />
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle<br />
weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require<br />
placarding.<br />
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some<br />
requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are<br />
as follows:<br />
1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one<br />
motor vehicle <strong>operator</strong>’s license.<br />
If you have more than one license, keep the license from your state of residence and return the additional<br />
licenses to the states that issued them. DESTROYING a license does not close the record in the state that<br />
issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record<br />
by notifying the state of issuance that you no longer want to be licensed by that state.<br />
2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:<br />
Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify<br />
your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In<br />
addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking),<br />
you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your<br />
license (If the violation occurs in a state other than the one which issued your license). The notification to<br />
both the employer and state must be in writing.<br />
The following license is the only one I will possess:<br />
Driver's License No.<br />
State<br />
Exp. Date<br />
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.<br />
Driver's Name (Printed):<br />
Driver’s Signature:_______________________________________ Date________________________<br />
Notes:<br />
(This form is not required for DOT compliance)<br />
90-F 1617<br />
© Copyright 2000 J.J. KELLER & ASSOCIATES, INC., Neenah, WI • USA • (800) 327-6868 • www.jjkeller.com • Printed in the United States (Rev. 10/00)
APPLICANT CONSENT AND RELEASE FORM<br />
COMPANY NAME: ________________________________________________________________<br />
ADDRESS:____________________________________________<br />
ZIP _____________<br />
PHONE NO.: ______________________________________________________________________<br />
In consideration for my being considered for employment, I, ____________________________ ,<br />
hereby give my consent to and authorize ________________________________________________<br />
the employer, to perform any testing or medical procedures necessary to determine the presence of<br />
alcohol or drugs in my body.<br />
I further give my consent to release to __________________________________________________<br />
or its designated agents, the results of any medical test performed, including any test or medical<br />
procedures to determine the level or presence of alcohol or drugs.<br />
I realize that my refusal to sign this form constitutes a violation of the employer's stated policy, and<br />
for that refusal, I will not be considered for, and knowingly waive any possibility of employment.<br />
I understand this consent and release shall be valid for my length of employment and that a copy of<br />
this consent form shall be valid as an original.<br />
_______________________________________<br />
Applicant Signature<br />
_________________________<br />
Date<br />
_______________________________________<br />
Witness Signature<br />
_________________________<br />
Date<br />
(Suggest you have your attorney look at and approve before using)
PRE-EMPLOYMENT URINALYSIS<br />
NOTIFICATION<br />
The Federal Motor Carrier Safety Regulations, Section 391.103 Pre-Employment Testing Requirements, apply<br />
to driver applicants of this company.<br />
391.103 PRE-EMPLOYMENT TESTING REQUIREMENTS.<br />
(a) A motor carrier shall require a driver-applicant who the motor carrier intends to hire or use pre-qualification<br />
condition.<br />
(b) A driver-applicant shall submit to controlled substance testing as a pre-qualification condition.<br />
(c) Prior to collection of the urine sample under FMCSR 391.107 of this subpart, a driver-applicant shall be<br />
notified that the sample will be tested for the presence of controlled substances.<br />
As a condition of employment, I agree to the urine sample collection and controlled substance testing.<br />
I understand a positive test for controlled substances based on the Urinalysis Test will medically disqualify me<br />
from the operation of a commercial motor vehicle for this company.<br />
The Medical Review Officer will maintain the results of the Urinalysis Test. Negative and Positive results will<br />
be reported to the company.<br />
My written authorization is required for the Urinalysis Tests to be given to other parties.<br />
I have read and understand the above conditions for the Pre-Employment Urinalysis Notification.<br />
_______________________________<br />
Applicant’s Name<br />
_______________________________<br />
Applicant’s Signature<br />
______________________<br />
Date<br />
Witnessed By:<br />
_______________________________<br />
Company Representative<br />
______________________<br />
Date
Name<br />
DRIVER'S<br />
APPLICATION FOR EMPLOYMENT<br />
Company<br />
Address<br />
City State Zip<br />
(answer all questions-please print)<br />
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions<br />
without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other<br />
protected group status.<br />
Date of Application<br />
Position Applied for<br />
List your addresses of residency for the past 3 years.<br />
Current Address<br />
Previous<br />
Addresses<br />
Street<br />
State Zip Code Phone yr./mo<br />
City<br />
How Long?<br />
How Long?<br />
Street City State & Zip Code yr./mo<br />
How Long?<br />
Street City State & Zip Code yr./mo<br />
How Long?<br />
Street City State & Zip Code yr./mo<br />
Do you have the legal right to work in the United States?<br />
Date of Birth<br />
(Required for Commercial Drivers)<br />
Have you worked for this company before?<br />
Can you provide proof of age?<br />
Where?<br />
Dates: From To Rate of Pay Position<br />
Reason for leaving<br />
Are you now employed?<br />
Who referred you?<br />
If not, how long since leaving your last employment?<br />
Rate of pay expected?<br />
Have you ever been bonded?<br />
Have you ever been convicted of a felony?<br />
Name of bonding company?<br />
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all<br />
circumstances will be considered.<br />
Emergency Contact Person<br />
NAME RELATIONSHIP PHONE NUMBER<br />
© Copyright 1998 J. J. KELLER & ASSOCIATES, INC., Neenah, WI • USA<br />
This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal,<br />
accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form,<br />
15F (Rev. 5/02) 691<br />
(800) 327-6868 • Printed in the United States<br />
or any decision made by an employer which may violate local, state, or federal law.
EMPLOYMENT HISTORY<br />
All applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List<br />
complete mailing address, street number, city, state and zip code.<br />
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on<br />
those employers for whom the applicant operated such vehicle.<br />
(Note: List employers in reverse order starting with the most recent. Add another sheet as necessary.)<br />
EMPLOYER<br />
DATE<br />
NAME<br />
ADDRESS<br />
CITY STATE ZIP CODE<br />
FROM<br />
POSITION HELD<br />
SALARY/WAGE<br />
TO<br />
CONTACT PERSON PHONE #<br />
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO<br />
REASON FOR LEAVING<br />
EMPLOYER<br />
DATE<br />
NAME<br />
ADDRESS<br />
CITY STATE ZIP CODE<br />
FROM<br />
POSITION HELD<br />
SALARY/WAGE<br />
TO<br />
CONTACT PERSON PHONE #<br />
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO<br />
REASON FOR LEAVING<br />
EMPLOYER<br />
DATE<br />
NAME<br />
ADDRESS<br />
CITY STATE ZIP CODE<br />
FROM<br />
POSITION HELD<br />
SALARY/WAGE<br />
TO<br />
CONTACT PERSON PHONE #<br />
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO<br />
REASON FOR LEAVING<br />
EMPLOYER<br />
DATE<br />
NAME<br />
ADDRESS<br />
CITY STATE ZIP CODE<br />
FROM<br />
POSITION HELD<br />
SALARY/WAGE<br />
TO<br />
CONTACT PERSON PHONE #<br />
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO<br />
REASON FOR LEAVING<br />
* Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle<br />
used to transport hazardous materials in a quantity requiring placarding.<br />
PAGE 2 15F (Rev. 5/02) 691
ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE<br />
LAST ACCIDENT<br />
DATES<br />
NATURE OF ACCIDENT<br />
(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES<br />
NEXT PREVIOUS<br />
NEXT PREVIOUS<br />
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE<br />
LOCATION<br />
DATE CHARGE PENALTY<br />
(ATTACH SHEET IF MORE SPACE IS NEEDED)<br />
EDUCATION<br />
CHECK HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4<br />
LAST SCHOOL ATTENDED<br />
(NAME)<br />
(CITY)<br />
EXPERIENCE AND QUALIFICATIONS - DRIVER<br />
DRIVER<br />
STATE LICENSE NO. TYPE EXPIRATION DATE<br />
LICENSES<br />
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO<br />
B. Has any license, permit or privilege ever been suspended or revoked? YES NO<br />
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS BELOW<br />
DRIVING EXPERIENCE CHECK ALL THAT APPLY<br />
CLASS OF EQUIPMENT<br />
TYPE OF EQUIPMENT<br />
(VAN, TANK, FLAT, ETC.)<br />
FROM<br />
DATES<br />
TO<br />
APPROX. NO. OF MILES<br />
(TOTAL)<br />
STRAIGHT TRUCK<br />
TRACTOR AND SEMI-TRAILER<br />
TRACTOR – TWO TRAILERS<br />
MOTORCOACH – SCHOOL BUS<br />
OTHER<br />
LIST STATES OPERATED IN FOR LAST FIVE YEARS<br />
LIST STATES OPERATED IN FOR LAST FIVE YEARS<br />
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER<br />
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?<br />
PAGE 3 15F (Rev. 5/02) 691
EXPERIENCE AND QUALIFICATIONS – OTHER<br />
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY<br />
LIST COURSES, TRAINING or CERTIFICATIONS THAT YOU MAY HAVE OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION<br />
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)<br />
TO BE READ AND SIGNED BY APPLICANT<br />
This certifies that this application was completed by me, and that all entries on it and information in it are true and<br />
complete to the best of my knowledge.<br />
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history<br />
and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries<br />
regarding medical history will be made only if and after a conditional offer of employment has been extended.) I<br />
hereby release employers, schools, health care providers and other persons from all liability in responding to<br />
inquiries and releasing information in connection with my application.<br />
In the event of employment, I understand that false or misleading information given in my application or interview(s)<br />
may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the<br />
Company.<br />
___________________________________<br />
DATE<br />
APPLICANT HIRED<br />
DATE EMPLOYED<br />
DEPARTMENT<br />
___________________________________________<br />
APPLICANTS SIGNATURE<br />
PROCESS RECORD<br />
REJECTED<br />
POINT EMPLOYED<br />
CLASSIFICATION<br />
(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)<br />
THIS SECTION TO BE FILLED IN BY RESPONSIBLE<br />
OFFICER OR COMPANY REPRESENTATIVE<br />
1.APPLICATION<br />
2.INTERVIEW<br />
3.PAST EMPLOYMENT<br />
4.WRITTEN EXAM<br />
5.ROAD TEST<br />
6.CRIMINAL AND TRAFFIC<br />
CONVICTIONS<br />
SUPERIOR GOOD FAIR BELOW AVERAGE POOR WRITTEN RECORD ON FILE<br />
FROM:<br />
DATE:<br />
SIGNATURE OF INTERVIEWING OFFICER ________________________________________________________________<br />
TRANSFERS<br />
TO:<br />
FROM:<br />
TO:<br />
DATE:<br />
REASON FOR TRANSFER:<br />
REASON FOR TRANSFER:<br />
FROM:<br />
TO:<br />
FROM:<br />
TO:<br />
DATE:<br />
DATE:<br />
REASON FOR TRANSFER:<br />
REASON FOR TRANSFER:<br />
TERMINATION OF EMPLOYMENT<br />
DATE TERMINATED<br />
DEPARTMENT RELEASED FROM<br />
DISMISSED VOLUNTARILY QUIT OTHER<br />
TERMINATION REPORT PLACED IN FILE<br />
SUPERVISOR<br />
PAGE 4 15F (Rev. 5/02) 691
Department of Homeland Security<br />
U.S. Citizenship and Immigration Services<br />
OMB No. 1615-0047; Expires 08/31/12<br />
Form I-9, Employment<br />
Eligibility Verification<br />
Read instructions carefully before completing this form. The instructions must be available during completion of this form.<br />
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT<br />
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a<br />
future expiration date may also constitute illegal discrimination.<br />
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)<br />
Print Name: Last First Middle Initial Maiden Name<br />
Address (Street Name and Number) Apt. # Date of Birth (month/day/year)<br />
City State<br />
Zip Code Social Security #<br />
I am aware that federal law provides for<br />
imprisonment and/or fines for false statements or<br />
use of false documents in connection with the<br />
completion of this form.<br />
Employee's Signature<br />
I attest, under penalty of perjury, that I am (check one of the following):<br />
A citizen of the United States<br />
A noncitizen national of the United States (see instructions)<br />
A lawful permanent resident (Alien #)<br />
An alien authorized to work (Alien # or Admission #)<br />
until (expiration date, if applicable - month/day/year)<br />
Date (month/day/year)<br />
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under<br />
penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.<br />
Preparer's/Translator's Signature<br />
Print Name<br />
Address (Street Name and Number, City, State, Zip Code)<br />
Date (month/day/year)<br />
Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR<br />
examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and<br />
expiration date, if any, of the document(s).)<br />
List A<br />
OR<br />
List B<br />
AND<br />
List C<br />
Document title:<br />
Issuing authority:<br />
Document #:<br />
Expiration Date (if any):<br />
Document #:<br />
Expiration Date (if any):<br />
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that<br />
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on<br />
(month/day/year)<br />
and that to the best of my knowledge the employee is authorized to work in the United States. (State<br />
employment agencies may omit the date the employee began employment.)<br />
Signature of Employer or Authorized Representative<br />
Print Name<br />
Title<br />
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)<br />
Date (month/day/year)<br />
Section 3. Updating and Reverification (To be completed and signed by employer.)<br />
A. New Name (if applicable)<br />
B. Date of Rehire (month/day/year) (if applicable)<br />
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.<br />
Document Title:<br />
Document #:<br />
Expiration Date (if any):<br />
l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented<br />
document(s), the document(s) l have examined appear to be genuine and to relate to the individual.<br />
Signature of Employer or Authorized Representative<br />
Date (month/day/year)<br />
Form I-9 (Rev. 08/07/09) Y Page 4
LISTS OF ACCEPTABLE DOCUMENTS<br />
All documents must be unexpired<br />
LIST A LIST B LIST C<br />
Documents that Establish Both<br />
Identity and Employment<br />
Authorization<br />
1. U.S. Passport or U.S. Passport Card<br />
2. Permanent Resident Card or Alien<br />
Registration Receipt Card (Form<br />
I-551)<br />
3. Foreign passport that contains a<br />
temporary I-551 stamp or temporary<br />
I-551 printed notation on a machinereadable<br />
immigrant visa<br />
4. Employment Authorization Document<br />
that contains a photograph (Form<br />
I-766)<br />
5. In the case of a nonimmigrant alien<br />
authorized to work for a specific<br />
employer incident to status, a foreign<br />
passport with Form I-94 or Form<br />
I-94A bearing the same name as the<br />
passport and containing an<br />
endorsement of the alien's<br />
nonimmigrant status, as long as the<br />
period of endorsement has not yet<br />
expired and the proposed<br />
employment is not in conflict with<br />
any restrictions or limitations<br />
identified on the form<br />
6. Passport from the Federated States of<br />
Micronesia (FSM) or the Republic of<br />
the Marshall Islands (RMI) with<br />
Form I-94 or Form I-94A indicating<br />
nonimmigrant admission under the<br />
Compact of Free Association<br />
Between the United States and the<br />
FSM or RMI<br />
OR<br />
Documents that Establish<br />
Identity<br />
1. Driver's license or ID card issued by<br />
a State or outlying possession of the<br />
United States provided it contains a<br />
photograph or information such as<br />
name, date of birth, gender, height,<br />
eye color, and address<br />
2. ID card issued by federal, state or<br />
local government agencies or<br />
entities, provided it contains a<br />
photograph or information such as<br />
name, date of birth, gender, height,<br />
eye color, and address<br />
3. School ID card with a photograph<br />
4. Voter's registration card<br />
5. U.S. Military card or draft record<br />
6. Military dependent's ID card<br />
7. U.S. Coast Guard Merchant Mariner<br />
Card<br />
8. Native American tribal document<br />
9. Driver's license issued by a Canadian<br />
government authority<br />
For persons under age 18 who<br />
are unable to present a<br />
document listed above:<br />
10. School record or report card<br />
11. Clinic, doctor, or hospital record<br />
12. Day-care or nursery school record<br />
AND<br />
Documents that Establish<br />
Employment Authorization<br />
1. Social Security Account Number<br />
card other than one that specifies<br />
on the face that the issuance of the<br />
card does not authorize<br />
employment in the United States<br />
2. Certification of Birth Abroad<br />
issued by the Department of State<br />
(Form FS-545)<br />
3. Certification of Report of Birth<br />
issued by the Department of State<br />
(Form DS-1350)<br />
4. Original or certified copy of birth<br />
certificate issued by a State,<br />
county, municipal authority, or<br />
territory of the United States<br />
bearing an official seal<br />
5. Native American tribal document<br />
6. U.S. Citizen ID Card (Form I-197)<br />
7. Identification Card for Use of<br />
Resident Citizen in the United<br />
States (Form I-179)<br />
8. Employment authorization<br />
document issued by the<br />
Department of Homeland Security<br />
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)<br />
Form I-9 (Rev. 08/07/09) Y Page 5
Contract Driver<br />
NAIT Association Program Insurance Application<br />
Applicant Name: Mr. Mrs. Ms.<br />
Last First Middle<br />
Address:<br />
Street/PO Box Apt City State Zip<br />
Social Security #: Date of Birth: Phone:<br />
CDL #: CDL State: What do you haul?<br />
Fleet Owner Name & Address: __________________________________________________________________________<br />
__________________________________________________________________________________________________<br />
Insurance services provided by TransGuard General Agency, Inc. (“TGA”); In California, doing business as TransGuard<br />
General Insurance Agency; In Utah, doing business as TransGuard General Insurance Agency, Inc. If you need coverage<br />
that is not addressed in this application, please contact TransGuard General Agency, Inc. at (800) 821-8014 for assistance.<br />
OCCUPATIONAL ACCIDENT<br />
Do you want to purchase Occupational Accident coverage for yourself? Yes* No<br />
*If yes, please complete the following information:<br />
How is your income reported: 1099 W-2 Height:_____Feet _____Inches Weight:______<br />
Please name a beneficiary for the payment of accidental death benefits. (Accidental death benefits are payable to<br />
your surviving spouse or dependent children, subject to the terms and conditions of this coverage. The beneficiary<br />
designation requested only applies when benefits are payable and you do not have a spouse or dependent children<br />
surviving.)<br />
Name of Beneficiary Address (Street/City/State/Zip) Relationship<br />
Have you been injured in a work-related accident during the past 36 months? Yes No<br />
Date of Accident/Injury: _________________________________________________________________________<br />
Explanation of Accident/Injury: ___________________________________________________________________<br />
____________________________________________________________________________________________<br />
Treatment Received: __________________________________________________________________________<br />
Have you received medical treatment for a health-related condition in the past 36 months? Yes No<br />
Describe health related condition and treatment received: ______________________________________________<br />
____________________________________________________________________________________________<br />
Are you presently taking any prescription medications? Yes No<br />
List medications and what conditions they are used to treat: ____________________________________________<br />
____________________________________________________________________________________________<br />
Do you have any health restrictions or limitations on the type of work you can perform? Yes No<br />
Describe restrictions and limitations: _______________________________________________________________<br />
____________________________________________________________________________________________<br />
Do you have a disability rating? Yes* No<br />
*If yes, give percentage: %_________ Disabled area:_____________________________________________________<br />
What caused the disability? _____________________________________________________________________<br />
When this coverage is provided, you will be insured under the Occupational Accident plan elected by your fleet<br />
<strong>owner</strong>’s motor carrier as satisfying their coverage requirements or the plan you elect if billed direct pay. You are<br />
also selecting Non-Occupational Accident Coverage with this purchase if your fleet <strong>owner</strong>’s motor carrier requires<br />
such coverage on the date of application. If Occupational Accident Coverage for a Helper / Co-driver or Partner is<br />
needed, a separate supplemental application must be completed. Contact TransGuard General Agency, Inc. for<br />
assistance.<br />
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 1 of 4<br />
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014
WORKERS’ COMPENSATION<br />
(Excludes sole-proprietor and partner, this coverage is for your casuals/helpers only)<br />
Do you want to purchase coverage for your casuals/helpers? Yes No<br />
Your FEIN / State Tax ID #: _________________________<br />
COMMERCIAL BUSINESS AUTO<br />
Do you want to purchase Physical Damage Coverage? Yes No<br />
Which Comprehensive/Collision Deductible? $250 $500 $1000 $2500<br />
Stated Amount: $ _____________<br />
Tractor Trailer Other: _______________________________________________________________________<br />
_________ _________________________________________ _____________________________________<br />
Year Manufacturer/Model/Gross Weight VIN#<br />
__________________________ ___________________________________________________________________<br />
Loss Payee (lien holder/lessor) Loss Payee Address<br />
NAIT MEMBERSHIP<br />
I understand that I must be a member of the National Association of Independent Truckers (“NAIT”) in order to participate in<br />
its insurance programs. If I am not currently a member, I will apply for membership. I may become and remain a member of<br />
NAIT without the purchase of NAIT sponsored insurance.<br />
POLICY TERMS AND CONDITIONS<br />
Coverage applied for under the NAIT insurance program is subject to all the terms, conditions and limitations of the policy<br />
providing the coverage requested.<br />
PAYMENT TERMS: I understand that the cost of this insurance is my sole obligation and responsibility, and I agree<br />
that I will pay upon demand or at any time my account remains unpaid, any amount due and owing. I also understand that if<br />
my insurance is canceled my deposit premium will be used to cover my outstanding premium. If the motor carrier to whom<br />
my fleet <strong>owner</strong> is under contract has agreed to settlement deduction arrangements for the payment of premium, I hereby<br />
APPOINT that motor carrier as my agent for receipt of NAIT Program billing notices and AUTHORIZE them to make<br />
deductions from my account equal to the cost of NAIT membership dues, benefits and insurance premiums and to remit<br />
same as required on my behalf. I also authorize the motor carrier named on page 4 of this application or on my Evidence of<br />
Coverage, if changed, to remit any deposit premium and/ or membership dues required for participation in NAIT’s insurance<br />
programs. Deposit premium is fully refundable upon termination of coverage if my account is current and in good standing. I<br />
understand there is a one-month deposit charge for NAIT membership dues and a one month deposit premium charge for all<br />
insurance coverages, except Workers’ Compensation. For Workers’ Compensation, a state mandated minimum charge, per<br />
policy, is applicable.<br />
AGREEMENTS<br />
I certify that I am DOT qualified and that I have complied with all applicable DOT requirements. I am not now, nor will I<br />
become, an employee of any motor carrier or fleet <strong>owner</strong> while any insurance provided through an NAIT program is in force.<br />
I authorize the release to TGA, its affiliated insurers and their representatives, if necessary: 1) all insurance documents<br />
related to me and/or my insured equipment; 2) my current Motor Vehicle Report (MVR), including updates as needed; 3)<br />
applicable medical records; 4) any test results in accordance with DOT regulations; 5) a copy of my current equipment lease<br />
agreement(s), if any; and 6) a copy of my independent contractor agreement with my fleet <strong>owner</strong>. I understand this<br />
information may be used for purposes of evaluating my application for insurance. I authorize the motor carrier listed on my<br />
Evidence of Coverage to request cancellation of my coverage whose premium is paid by settlement deduction arrangements<br />
when I am no longer under contract to my fleet <strong>owner</strong> or when my fleet <strong>owner</strong> is no longer under contract to that motor<br />
carrier. I understand NAIT, as group policyholder, has authority to execute and cancel all group coverage. I knowingly reject<br />
statutory Workers’ Compensation coverage when opting for Occupational Accident coverage, if required by state law.<br />
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 2 of 4<br />
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014
AGREEMENTS (CONTINUED)<br />
Applicable To Occupational Accident coverage only: I further understand and agree that as an independent contractor<br />
and in choosing this Occupational Accident coverage, I am not able to file nor otherwise assert any claim for statutory<br />
Workers’ Compensation benefits against my fleet <strong>owner</strong>, my fleet <strong>owner</strong>’s motor carrier and/or any insurers or other<br />
companies related to such entities. I further agree to indemnify and forever hold harmless NAIT, my fleet <strong>owner</strong>, my fleet<br />
<strong>owner</strong>’s motor carrier and/or any insurers or other companies related to any of the foregoing entities of and from any and all<br />
claims that may be made by me or by anyone else on my behalf for statutory Workers’ Compensation benefits.<br />
A credit report or other investigative report about me may be requested in connection with this application for insurance and<br />
subsequent renewals. Any information about me or which I have provided about anyone will be treated confidentially.<br />
However, this information, as well as other non-public personal or privileged information subsequently collected, may, under<br />
certain circumstances, be disclosed without prior authorization to non-affiliated third parties. Information may be shared with<br />
affiliated companies for such purposes as claims handling, servicing, underwriting and insurance marketing. I have the right<br />
to see personal information collected about me, and I have the right to correct any information which may be wrong. A<br />
description of TGA’s information practices, and my rights regarding information TGA collects may be obtained by contacting<br />
TGA.<br />
I certify the information that I have provided in this application is true, complete and accurately recorded to the best of my<br />
knowledge and belief. I understand this information will be used to apply for insurance coverage on my behalf. If approved,<br />
this application will be attached to and made a part of each policy providing the coverage requested. I certify that I have<br />
fulfilled all requirements to work legally in the U.S. by 1) being a U.S. citizen and/or 2) being in full compliance with all Federal<br />
laws and/or regulations regarding work eligibility. I understand that the giving of any inaccurate, false, or misleading<br />
information on this application may result in rejection of this application and the denial of benefits under any and all<br />
insurance coverage for which I have applied.<br />
FRAUD WARNINGS<br />
Fraud Warning applicable to residents of all states except those listed below and Nebraska: Any person who knowingly and with<br />
intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially<br />
false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent<br />
insurance act, which is a crime and subjects such person to criminal and civil penalties.<br />
ADDITIONAL STATE SPECIFIC FRAUD LANGUAGE<br />
IN ARKANSAS, LOUISIANA AND MARYLAND - Any person who knowingly presents a false or fraudulent claim for payment of a loss or<br />
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and<br />
confinement in prison.<br />
IN CALIFORNIA - For your protection California law requires the following to appear on this form: Any person who knowingly presents a<br />
false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.<br />
IN COLORADO - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the<br />
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil<br />
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or<br />
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to<br />
a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of<br />
Regulatory Agencies.<br />
IN DISTRICT OF COLUMBIA – Warning: It is a crime to provide false or misleading information to an insurer for the purpose of<br />
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance<br />
benefits if false information materially related to a claim was provided by the applicant.<br />
IN FLORIDA - Any person who knowingly and with intent in injure, defraud, or deceive any insurer files a statement of claim or an<br />
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.<br />
IN HAWAII - For your protection, Hawaii law requires you to be informed that any person who presents a fraudulent claim for payment of<br />
a loss or benefit is guilty of a crime punishable by fines or imprisonment, or both.<br />
IN KENTUCKY – Any person who knowingly and with intent to defraud any insurance company or other person files an application for<br />
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material<br />
thereto commits a fraudulent insurance act, which is a crime.<br />
IN MAINE - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of<br />
defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.<br />
INITIAL/DATE:________________<br />
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 3 of 4<br />
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014
ADDITIONAL STATE SPECIFIC FRAUD LANGUAGE (CONTINUED)<br />
IN NEW JERSEY - Any person who includes any false or misleading information on an application for an insurance policy is subject to<br />
criminal and civil penalties<br />
IN NEW MEXICO - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents<br />
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.<br />
IN NEW YORK - Any person who knowingly and with intent to defraud any insurance company or other person files an application for<br />
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information<br />
concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another<br />
to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department<br />
of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil<br />
penalty not to exceed $5,000 and the value of the subject motor vehicle or stated claim for each violation.<br />
IN OHIO - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or<br />
files a claim containing a false or deceptive statement is guilty of insurance fraud.<br />
IN OKLAHOMA - Warning – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for<br />
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.<br />
IN OREGON - Any person who knowingly and with intent to defraud any insurance company or another person files an application for<br />
insurance or statement of claim containing any materially false information may be subject to prosecution for insurance fraud.<br />
IN PENNSYLVANIA – Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing<br />
any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of<br />
a fine of up to $15,000.<br />
IN TENNESSEE, VIRGINIA AND WASHINGTON - It is a crime to knowingly provide false, incomplete or misleading information to an<br />
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.<br />
I UNDERSTAND AND AGREE THAT COVERAGE REQUESTED IN THIS APPLICATION WILL NOT BE AFFORDED<br />
UNTIL THIS APPLICATION IS SUBMITTED AND I AM APPROVED. I CERTIFY AND REPRESENT THAT I HAVE READ<br />
AND UNDERSTAND THIS APPLICATION USING TRANSLATION SERVICES AS NEEDED AND THAT THE<br />
INFORMATION I HAVE PROVIDED AND THE REPRESENTATIONS I HAVE MADE HEREIN ARE TRUE AND CORRECT.<br />
I certify that I am an independent contractor and not an employee of my fleet <strong>owner</strong> or my fleet <strong>owner</strong>’s motor carrier.<br />
APPLICANT SIGNATURE<br />
DATE<br />
MOTOR CARRIER NAME/TERMINAL LOCATION<br />
UNIT NUMBER<br />
I certify that I am an independent contractor and not an employee of any motor carrier and that the applicant is not my<br />
employee but is an independent contractor working on my behalf.<br />
FLEET OWNER SIGNATURE<br />
DATE<br />
____________________________________<br />
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 4 of 4<br />
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014
!<br />
Direct Deposit Authorization Form<br />
Please print and complete ALL the information below.<br />
Name:<br />
Address:<br />
City, State, Zip:<br />
____________________________________________________________<br />
____________________________________________________________<br />
____________________________________________________________<br />
Name of Bank:<br />
Account #:<br />
9-Digit Routing #:<br />
____________________________________________________________<br />
____________________________________________________________<br />
____________________________________________________________<br />
Amount: $ ______________ _______% or Entire Paycheck<br />
Type of Account: Checking Savings<br />
Please attach a voided check for each bank account to which funds should be deposited.<br />
__________________________ is hereby authorized to directly deposit my pay to the account<br />
listed above. This authorization will remain in effect until I modify or cancel it in writing.<br />
Employee Signature: ___________________________<br />
Date: ______________________
INDEPENDENT CONTRACTOR AGREEMENT<br />
FOR OWNER-OPERATOR<br />
THIS AGREEMENT is made this<br />
in the State of ILLINOIS by and between<br />
R2R Intermodal Inc. a regulated for hire motor carrier, an IL corporation and<br />
("CONTRACTOR"), as follows:<br />
WHEREAS, R2R Intermodal Inc is engaged in business to provide trucking service for different customers and<br />
intends to contract with CONTRACTOR in the performance of certain tasks;<br />
WHEREAS, between R2R Intermodal Inc. principal place of business is located at the following address: 2636<br />
West Foster Ave Chicago, IL 60625<br />
WHEREAS, CONTRACTORS principal place of business is located at the following address:<br />
_____________________________________________________________________________________________<br />
_____________________________________________________________________________________________<br />
WHEREAS, CONTRACTOR is doing business at a (check one):<br />
Partnership Sole Proprietorship Corporation<br />
NOW THEREFORE, in consideration of the mutual covenants herein contained the sufficiency of which is<br />
acknowledged, it is agreed as follows:<br />
1. Effective Date<br />
This agreement shall become effective upon signing by both parties and shall remain in effect for one (1)<br />
year from date of signing, and shall automatically renew for additional like periods, not to exceed a total of<br />
three (3) years unless: sooner canceled.<br />
2. Termination<br />
This Agreement may be terminated:<br />
A. Without cause, upon either party giving the other thirty (30) days prior written notice; or<br />
B. For cause, immediately, upon material breach of any term of this Agreement by either of the parties.<br />
C. CONTRACTOR has the right to terminate this Agreement under the terms stated herein. In accordance<br />
with Section 212.1 (a) (2) of the Illinois Unemployment Insurance Act, following termination,<br />
CONTRACTOR has the right to perform the same or similar services, on whatever basis and whenever<br />
CONTRACTOR chooses, for persons or entities other than R2R Intermodal Inc. except as limited by<br />
the requirements promulgated by regulations of the Federal Highway Administration Illinois commerce<br />
Commission, or any other regulatory body having jurisdiction.<br />
3. Registration/Licensing of R2R Intermodal Inc.<br />
A. Such as contemplated by Section 212.1 (a)(1) of the Illinois Unemployment Insurance Act R2R<br />
Intermodal Inc. is a for hire motor carrier authorized to transport property pursuant to licenses issued by<br />
Page 1 of 10
the Federal Highway Administration (successor in interest to the Interstate Commerce Commission) and<br />
other federal and state operating authorities and licenses.<br />
B. R2R Intermodal Inc. will use said Equipment in its business as a motor carrier, under its various<br />
certificates or permits which it now holds or which it may subsequently acquire, where such are<br />
required. Such Equipment furnished to R2R Intermodal Inc. shall be exclusively used in R2R<br />
Intermodal Inc. business to the extent required by all applicable laws and regulations. Said Equipment<br />
shall, during the term of this Agreement, be under R2R Intermodal Inc. exclusive possession, use and<br />
control, to the extent contemplated by and required by all applicable federal and state laws and<br />
regulations relating to the operation of leased motor vehicle equipment by motor carriers R2R<br />
Intermodal Inc. assumes full responsibility for the operation of said Equipment as to all third parties and<br />
the public at large. However, this shall no way modify, alter or affect CONTRACTOR’S status as an<br />
Independent Contractor, and not an employee of R2R Intermodal Inc. Nothing in this Agreement shall<br />
be deemed as a delegation of R2R Intermodal Inc. duties as a common or contract or contract carrier to<br />
CONTRACTOR in so far as the public or any governmental or regulatory body may be concerned. The<br />
terms of this Agreement are merely an assignment and distribution of various costs arising out of the<br />
operations to be conducted pursuant to this Agreement, between the parties to this Agreement.<br />
4. Ownership of Equipment<br />
In accordance with Section 212.1(a) (4) of the Illinois Unemployment Insurance Act. CONTRACTOR<br />
declares that it holds title to (or is otherwise legally entitled to lease) said Equipment and does lease to R2R<br />
Intermodal Inc. The Equipment described in Appendix “A,” attached to this Agreement and made a part hereof.<br />
That equipment is referred to in this Agreement as “Equipment.”<br />
5. Name and Address on CONTRACTOR’S EQUIPMENT<br />
In accordance with Section 212.1 (a) (6) of the Illinois Unemployment Insurance Act, CONTRACTOR<br />
agrees to display its business name and address on all Equipment covered by this Agreement. Any such display<br />
of business name and address shall comply with applicable law and with the rules and regulations of the United<br />
States Department of Transportation.<br />
6. Availability and Scheduling<br />
In accordance with Section 212.1 (a) (3) of the Illinois Unemployment Insurance Act, CONTRACTOR is<br />
not required by R2R Intermodal Inc. to perform service or be available to perform services at specific times or<br />
according to a schedule or for a number of hours specified by R2R Intermodal Inc. However, pickup or delivery<br />
times specified by a shipper, receiver, broker, or other party that owns or controls a shipment shall not be deemed<br />
“specified” by.<br />
7. Licensing and Operating Costs<br />
A. CONTRACTOR’s Costs, In accordance with Section 212.1 (a) (5) of the Illinois Unemployment<br />
Insurance Act, CONTRACTOR shall pay all costs of licensing and operating the Equipment (except<br />
when federal or state law or regulation requires R2R Intermodal Inc to pay), and no costs of such<br />
licensing or operating shall be separately reimbursed by any other person or entity. Also,<br />
CONTRACTOR agrees to pay a reasonable rental, to be negotiated between the parties, If<br />
CONTRACTOR desires to rent trailer(s). CONTRACTOR agrees that the Equipment described herein<br />
will be kept and maintained in first-class condition and repair at CONTRACTOR’S sole expense.<br />
Page 2 of 10
CONTRACTOR agrees to pay all of the expenses incurred in operating the Equipment which is the<br />
subject of this Agreement, without limitation, including, but not limited to, those items enumerated in<br />
49 C.F.R. §376.12(e) cost of fuel, fuel taxes, empty miles, permits of all types, tolls, ferries, detention,<br />
accessorial services, base plates and licenses, and the unused portion of such items]. Upon failure of<br />
CONTRACTOR to make such payments, R2R Intermodal Inc. may avail itself of any remedies<br />
described in Paragraph (2) herein or elsewhere in this Agreement.<br />
B. SAFETY COMPLIANCE, CONTRACTOR warrants that the Equipment leased herein complies with<br />
all of the required safety rules and complies with all rules and regulations of the United States<br />
Department of Transportation, and any and all federal, state or local regulatory bodies having<br />
jurisdiction over the operation of said Equipment, and that all taxes, of any nature, assessable against the<br />
leased Equipment or its operation have been paid. All costs incurred in connection with causing the<br />
Equipment leased hereunder to comply with said rules and regulations and any loss, damage or expense<br />
of any nature, whatsoever, which shall result from CONTRACTOR’S failure to ensure such<br />
compliance, shall be borne by CONTRACTOR. Upon failure of CONTRACTOR to promptly and<br />
immediately ensure such compliance and pay such costs or expenses R2R Intermodal Inc. pay, at its<br />
exclusive option, effect such compliance, pay such costs or expenses, and deduct the amount of such<br />
payment, together with any administrative expenses incurred in so doing, from any monies due of which<br />
may become due to CONTRACTOR pursuant to this Agreement. Before making any such deduction,<br />
R2R Intermodal Inc. shall give CONTRACTOR an itemized statement, setting forth the amount and<br />
allocation of any such deductions.<br />
C. LICENSE PLATES, CONTRACTOR shall purchase and pay for all license plates necessary for the<br />
operation of the equipment leased herein, in CONTRACTOR’S name, and said license plates shall<br />
remain the sole property of CONTRACTOR.<br />
D. CHARGES, Neither CONTRACTOR nor any personnel furnished by CONTRACTOR shall charge any<br />
purchases, of any nature. To R2R Intermodal Inc., should CONTRACTOR or its personnel, in violation<br />
of this Paragraph, charge any purchases to R2R Intermodal Inc. R2R Intermodal Inc. shall have the<br />
right to set off and deduct the amount of any such charges, together with any administrative expenses<br />
incurred, from any monies due or which may become due to CONTRACTOR pursuant to this<br />
Agreement and to avail itself of any other remedies described elsewhere in this Agreement. Before so<br />
doing, shall give CONTRACTOR a written statement of all such charges and set-offs.<br />
E. ADVANCES, In the event that R2R Intermodal Inc. shall be required to make any advances or<br />
payments for and/or on behalf of CONTRATOR’S obligation for necessary operating expenses or<br />
repairs on said Equipment, then R2R Intermodal Inc. shall have the right to withhold an equivalent sum,<br />
plus any administrative expenses incurred by R2R Intermodal Inc., in making such advances, as a setoff,<br />
from funds due CONTRACTOR as rental payment hereunder, or from any other sums which R2R<br />
Intermodal Inc. may owe to CONTRACTOR, to secure the repayment of any such advances or<br />
payments. R2R Intermodal Inc. will first give CONTRACTOR an itemized written statement for, or<br />
explanation of, all deductions made. CONTRACTOR hereby authorizes irrevocably any agent of any<br />
court of record to appear for CONTRACTOR in such court and confess judgment, without process, on<br />
favor of R2R Intermodal Inc. for such amounts of any advance or payments which R2R Intermodal Inc.<br />
has made on behalf of CONTRACTOR which remains unpaid, together with reasonable costs of<br />
collection, including attorneys’ fees, and to waive and release all errors which may intervene in any<br />
such judgment, hereby ratifying and confirming all that said attorney may do by virtue hereof.<br />
Page 3 of 10
F. R2R Intermodal Inc. NOT LIABLE, R2R Intermodal Inc. shall not, in any way, be liable for fire, theft,<br />
loss or damage to the Equipment leased hereunder, no matter how arising.<br />
G. INSURANCE, it is recognized that the United States Department of Transportation and various other<br />
regulatory bodies require the carrier under whose certificates or permits leased Equipment is being<br />
operated to be responsible to the public with respect to such Equipment while some is being operated<br />
under its authority. R2R Intermodal Inc. will file, or has on file, with the United States Department of<br />
Transportation and any other regulatory body having jurisdiction over its operations, evidence of<br />
insurance in such amounts as may be required by law or regulation of said agencies, and will<br />
continuously maintain in effect insurance in such amount.<br />
CONTRACTOR shall secure, at its sole expense, insurance in the minimum amount of $1,000,000<br />
combined single limits covering bob-tail and dead-heading on the Equipment leased herein and shall<br />
furnish R2R Intermodal Inc. with a certificate naming R2R Intermodal Inc as an additional insured<br />
thereunder. In addition, CONTRACTOR will carry at its sole expense, its own insurance coverage on<br />
the Equipment leased for collision, fire, theft and other occurrence or catastrophe, and R2R Intermodal<br />
Inc. shall be named as an insured thereunder also.<br />
R2R Intermodal Inc. shall furnish and may charge back to CONTRACTOR all costs of public liability,<br />
property damage, cargo and comprehensive insurance on the Equipment which is the subject of this<br />
Agreement, while it is operated in the service of R2R Intermodal Inc. The actual amount to be charged<br />
to CONTRACTOR for said insurance coverages shall be as act forth in APPENDIX “B” of this<br />
Agreement. Further R2R Intermodal Inc. shall furnish CONTRACTOR with copies of and the policy<br />
numbers of all such insurance policies, as well as certificates of insurance therefore containing all of the<br />
information required by 49 C.F.R. §376.12(j) (2). CONTRACTOR’S responsibility to indemnify R2R<br />
Intermodal Inc. for claims or losses, as set forth in this Agreement, is limited to the extent that such<br />
claims or losses, or any portion thereof, are not covered by such insurance policies.<br />
8. Insurance/Benefits/Warranties<br />
A. INSURANCE COVERAGES, CONTRACTOR will carry, at the own expense, the following insurance<br />
coverages with the described minimum limits:<br />
1) Commercial General Liability Coverage. Commercial general liability coverage with $1,000,000<br />
per occurrence limits.<br />
2) Commercial Automobile Coverage. Commercial automobile coverage with minimum limits of<br />
$1,000,000 combined single limit and $1,000,000 uninsured/underinsured coverage.<br />
CONTRACTOR must prove that its coverage is primary and acceptable to R2R Intermodal Inc. To<br />
determine this, CONTRACTOR will provide R2R Intermodal Inc. with a duplicate copy of its<br />
commercial auto policy. R2R Intermodal Inc will notify CONTRACTOR within thirty (30) days of<br />
acceptance if coverage or certificate is not acceptable.<br />
3) Workers’ Compensation Coverage or Occupational Accident Insurance. CONTRACTOR shall<br />
maintain workers’ compensation coverage for CONTRACTOR, its agents, servants and employees.<br />
B. CERTIFICATE OF INSURANCE. CONTRACTOR will furnish R2R Intermodal Inc an insurance<br />
certificate for all required coverages shown above naming R2R Intermodal Inc. as an “Additional<br />
Insured” on the general liability and commercial auto liability coverages. Contractor or its insurance<br />
Page 4 of 10
carrier(s) shall give R2R Intermodal Inc not less than thirty (30) days prior notice of any cancellation of<br />
any insurance policy or coverage(s) or such cancellation shall not be effective as to R2R Intermodal Inc.<br />
C. NO BENEFITS. CONTRACTOR further understands and agrees that CONTRACTOR and<br />
CONTRACTOR’S subcontractor, agents or employees are not entitled to any employee benefits<br />
normally granted to R2R Intermodal Inc’s employees, and CONTRACTOR shall indemnify and hold<br />
R2R Intermodal Inc. forever harmless from any and all liabilities (including expense and attorneys’<br />
fees) and all costs, loss, expenses or damages are arising from employee compensation or benefits,<br />
unemployment, Social Security or any other tax deduction or any employee benefits including, but not<br />
limited to, group accident and health insurance or any workers’ compensation claims, injuries to or<br />
omissions of CONTRACTOR or CONTRACTOR’S subcontractors, agents or employees for failure to<br />
comply with the terms and obligations of this Agreement.<br />
D. CONTRACTOR NOT COVERED. It is expressly understood and agreed that, because of<br />
CONTRACTOR’S independent contractor status, R2R Intermodal Inc. is not obligated to carry any<br />
insurance covering CONTRACTOR, including workers’ compensation insurance, and that<br />
CONTRACTOR shall be responsible for the payment of premiums on any health, liability, or accident<br />
insurance carried by CONTRACTOR for its protection, or the protection of its subcontractors, agents<br />
and employees.<br />
E. DRIVERS QUALIFIED. CONTRACTOR warrants that CONTRACTOR will furnish to operate all<br />
Equipment leased pursuant to this Agreement only drivers or personnel who are qualified and<br />
competent. CONTRACTOR agrees that all drivers and personnel furnished will be required to meet all<br />
of the rules and regulations o the United States Department of Transportation, and any other regulatory<br />
body having jurisdiction as to safety, hours of service, inspection and maintenance, the taking of<br />
physical examinations, and furnishing a certificate therefore. All drivers and personnel will be required<br />
to comply as to the qualifications, training program, drug and alcohol testing and safety rules of the<br />
United States Department of Transportation, and any other body having jurisdiction. It is further agreed<br />
that all drivers and personnel furnished by CONTRACTOR shall comply with all rules and regulations<br />
prescribed by any regulatory body having jurisdiction over the operations to be conducted pursuant to<br />
this Agreement. CONTRACTOR will ensure that all records pertaining to the foregoing will be<br />
furnished to R2R Intermodal Inc. In order that R2R Intermodal Inc. can keep and maintain such<br />
records in accordance with the rules and regulations of all regulatory bodies having jurisdiction over<br />
these operations.<br />
F. FINES AND PENALTIES. R2R Intemrodal Inc shall not be responsible for any fine, expenses or<br />
costs incurred by CONTRACTOR or any drivers or personnel furnished by CONTRACTOR, by reason<br />
of its or their violation of, or failure to adhere to, any federal or state law, local ordinance or regulation,<br />
or rule or regulation of any federal, state or local regulatory body having jurisdiction; provided,<br />
however, that R2R Intermodal Inc. agrees to pay all fines and penalties inadequacies in operating<br />
authorities or license where it is mandatory that such be issued in R2R Intermodal Inc. R2R Intermodal<br />
Inc. shall be responsible for fines for overweight or over-dimension trailers when trailers are pre-loaded<br />
sealed or the load is containerized, or when the trailer or lading is otherwise outside of<br />
CONTRACTOR’S control, except when such fine shall be the result of an act or mission of<br />
CONTRACTOR or personnel furnished by CONTRACTOR.<br />
G. CONTRACTOR’S PERSONNEL. As between R2R Intermodal Inc. and CONTRACTOR, except as<br />
may be otherwise required by law or regulation, CONTRACTOR shall be solely responsible for the<br />
direction and supervision of all personnel furnished by CONTRACTOR in connection with this<br />
Page 5 of 10
Agreement, including, but not limited to, the selection, hiring, firing, supervising, directing, training,<br />
setting wages, hours and working conditions, paying and adjusting grievances. As between<br />
CONTRACTOR and R2R Intermodal Inc. only, CONTRACTOR shall be solely and exclusively<br />
responsible for all aspects of the operation of the Equipment leased hereunder.<br />
9. Compensation<br />
A. The compensation and additional terms affecting payment of that compensation are stated in<br />
APPENDIX “B,” attached to this Agreement and made a part hereof.<br />
B. In order that CONTRACTOR may verify the accuracy of all payments made pursuant to this<br />
Agreement, where payment is predicated upon a percentage of gross revenues, R2R Intermodal Inc.<br />
shall present CONTRACTOR with copies of rated freight bills, or a computer-generated document<br />
containing all of the same information, for all shipments transported in or with equipment leased<br />
pursuant to this Agreement. CONTRACTOR shall have the right to examine copies of R2R Intermodal<br />
Inc. tariffs or rate schedules at R2R Intermodal Inc. home office during reasonable business hours. In<br />
those circumstances when CONTRACTOR is given a computer-generated document rather than a copy<br />
of a freight bill, CONTRACTOR shall have the right to examine the source document(s) from which<br />
such computer-generated information was compiled, under the same conditions. However, R2R<br />
Intermodal Inc. shall have the right to block out or obliterate all references on such freight bills, source<br />
document(s), tariffs and rate schedules as to the identity of customers, shippers and consignees.<br />
10. CONTRACTOR’s General Duties<br />
A. INSPECTION/WARRANTY. R2R Intermodal Inc. shall, prior to taking possession of the<br />
Equipment, Inspect said equipment. CONTRACTOR warrants that the Equipment is complete with all<br />
required accessories, appurtenances and appliances, and that the same is in good, safe and efficient<br />
operating condition and shall be so maintained, at CONTRACTOR’S sole expense throughout the<br />
duration of this Agreement. CONTRACTOR shall and will submit said Equipment for R2R Intermodal<br />
Inc. Inspection at the time R2R Intermodal Inc. takes possession and periodically thereafter, as required<br />
by R2R Intermodal Inc. CONTRACTOR shall furnish R2R Intermodal Inc. with all necessary<br />
information and documents of title or registration so as to enable R2R Intermodal Inc. to correctly<br />
identify and license the Equipment. CONTRACTOR shall furnish R2R Intermodal Inc copies of all<br />
statements or invoices for repairs to said Equipment on a monthly basis, whether than by<br />
CONTRACTOR or by a third party. R2R intermodal Inc. reserves the right to inspect the Equipment at<br />
any time, and if R2R Intermodal Inc exercises this right and the Equipment shall be utilized in R2R<br />
Intermodal Inc. service, as R2R Intermodal Inc. sees fit, CONTRACTOR shall not hinder or deter R2R<br />
Intermodal Inc’s utilization in any manner whatsoever, Nothing in this Paragraph or Agreement shall<br />
obligate R2R Intermodal Inc. utilize said Equipment with any specific frequency, for any specific<br />
number or miles, trips or pounds of freight.<br />
B. RECEIPTS FOR EQUIPMENT. When possession of said Equipment is taken by R2R Intermodal<br />
Inc. under the terms of this Agreement, R2R Intermodal Inc. shall issue to CONTRACTOR, on the form<br />
attached hereto as APPENDIX “C,” a receipt for said Equipment, stating the date and time at which<br />
possession is taken. When possession is retaken by CONTRACTOR, CONTRACTOR shall give R2R<br />
Intermodal Inc. a similar receipt on the form attached hereto as APPENDIX “C.” This Agreement shall<br />
not be considered terminated, for the sole purpose of calculating the time limits for payment of trip<br />
settlements due to CONTRACTOR hereunder, until CONTRACTOR has given R2R Intermodal Inc.<br />
its receipt, as act forth herein above acknowledging return of the Equipment to CONTRACTOR. Upon<br />
Page 6 of 10
termination of this Agreement, R2R Intermodal Inc. shall not be obligated to pay any accrued rentals<br />
due to CONTRACTOR in connection with said Equipment, until after CONTRACTOR’S receipt for<br />
the Equipment is received by<br />
11. Subleasing/Trip Leasing/Etc.<br />
A. R2R Intermodal Inc. may sublease the Equipment which is the subject of this Agreement whenever<br />
permitted by applicable laws and regulations, and R2R Intermodal Inc. shall be considered to be the<br />
<strong>owner</strong> of said Equipment for the purpose of any such subleasing if such is required by law or<br />
regulation. Neither party may assign this Agreement. CONTRACTOR may not act as R2R Intermodal<br />
agent for the trip of sublease of the subject Equipment, except upon such express terms and conditions<br />
as R2R Intermodal Inc. may establish. In the event that CONTRACTOR trip-leases the subject<br />
Equipment without first having obtained R2R Intermodal Inc. approval, then R2R Intermodal Inc shall<br />
not be responsible to CONTRACTOR for the payment of any monies relating to said trip lease, unless<br />
and until R2R Intermodal Inc. has actually received payment from the trip-lease carrier, nor shall R2R<br />
Intermodal Inc. be responsible for any obligations to any trip-lessee undertaken by CONTRACTOR<br />
Further, it is the responsibility of CONTRACTOR to submit all paper work relating to a trip-lease<br />
shipment to R2R Intermodal Inc. and not to the trip-lease carrier. R2R Intermodal Inc shall then<br />
immediately forward said paperwork to the trip-lease carrier.<br />
B. Consistent with its independent contractor status, CONTRACTOR is free to, and may, lease or trip to<br />
other carriers at such times as the Equipment that is not being utilized by R2R Intermodal Inc, If<br />
CONTRACTOR enters into a sublease, CONTRACTOR agrees to assume all responsibility and hold<br />
R2R Intermodal Inc harmless from any claim by CONTRACTOR, its subcontractors, agents or<br />
employees during such sublease.<br />
C. At those times when CONTRACTOR is not operating under R2R Intermodal Inc. operating authorities<br />
or otherwise operating in R2R Intermodal Inc. service pursuant to this Agreement, or is hauling for<br />
someone else, CONTRACTOR agrees to cover or remove any signs and/or other identification on the<br />
Equipment containing R2R Intermodal Inc. name and or motor carrier identification numbers.<br />
12. Indemnification by Contractor<br />
As between R2R Intermodal Inc. and CONTRACTOR only, without any regard or effect upon the<br />
obligation R2R Intermodal Inc. any third party, CONTRACTOR agrees to be responsible for, indemnify and<br />
hold R2R Intermodal Inc. harmless from any and all claims of any nature, losses, personal injury, death, and/or<br />
damage to cargo or other property, and/or claim for any such loss or occurrence which may arise from or in<br />
connection with the operations performed or to be performed pursuant to this Agreement, however arising,<br />
without regard to fault or negligence on the part of CONTRACTOR. This is to include, but is not limited to,<br />
attorneys’ fees and any other expenses incurred in defending or processing any claim arising as a result of any of<br />
the above or operation of the Equipment leased herein. R2R Intermodal Inc. may deduct any sums for which<br />
CONTRACTOR is responsible hereunder from any monies that R2R Intermodal Inc. may owe to<br />
CONTRACTOR as rentals or from any other sums which R2R Intermodal Inc. may owe to CONTRACTOR<br />
after first giving CONTRACTOR on itemized statement therefore.<br />
Page 7 of 10
13. Miscellaneous Provisions<br />
A. LABOR DISPUTE. CONTRACTOR hereby agrees that should it become involved in a labor<br />
dispute with its employees or with drivers or other personnel furnished to R2R Intermodal Inc. It<br />
will immediately report such fact to R2R Intermodal Inc. If such labor dispute interferes or tends to<br />
interfere with the operations of CONTRACTOR for R2R Intermodal Inc. pursuant to this<br />
Agreement, then this Agreement shall be subject to immediate cancellation by R2R Intermodal Inc.<br />
without penalty.<br />
B. RENT/PURCHASE. CONTRACTOR is not required to purchase or rent any products, equipment<br />
or service from R2R Intermodal Inc. as a condition of this Agreement.<br />
C. LOADING/UNLOADING. Loading of freight onto the Equipment, which is the subject of this<br />
Agreement, is the responsibility of CONTRACTOR and shall be done at CONTRACTOR’S<br />
expense. Unloading of freight is the responsibility of CONTRACTOR and shall be done at<br />
CONTRACTOR’S expense.<br />
D. R2R Intermodal Inc’s TRAILER. In the event that a vehicle leased from CONTRACTOR<br />
pursuant to this Agreement shall be utilized pulling trailer or chassis furnished by R2R Intermodal<br />
Inc. and during the course of any such operation any such trailer should become damaged,<br />
regardless of how such damage may occur, by or during said operations, then CONTRACTOR<br />
shall pay to R2R Intermodal Inc. all such damages to said trailer and all other consequential<br />
damages which R2R Intermodal Inc. may suffer flowing there from, after first giving<br />
CONTRACTOR credit for any sums recovered by R2R Intermodal Inc. by way of insurance or<br />
otherwise, with regard to said trailer.<br />
E. COMPLETE AGREEMENT. This Agreement shall supersede, replace and take precedence over<br />
any prior agreement of a similar character between the parties hereto. This Agreement shall<br />
constitute the complete Agreement between the parties, and no agent or employee of either party<br />
shall have the authority to alter or vary the terms hereof or to make any representations or<br />
commitments not included herein. This Agreement shall not be assignable except with the express<br />
written consent of both parties. This Agreement shall be interpreted and governed pursuant to the<br />
laws of State IL and any action pertaining thereto shall be brought and maintained exclusively in<br />
Courts in the State of IL.<br />
F. COPIES. This Agreement shall be executed in at least three (3) copies, each of which shall be<br />
considered an original, to the end that one executed copy, known as “R2R Intermodal Inc. Copy”<br />
shall be retained by R2R Intermodal Inc. one executed copy known as “CONTRACTOR’S Copy”<br />
shall be retained by CONTRACTOR; and one executed copy known as “Equipment Copy” shall be<br />
carried in the Equipment during the term of this Agreement and returned to R2R Intermodal Inc. at<br />
the conclusion of this Agreement. Additional copies may be signed where necessary, and, when<br />
signed, such additional copies shall also be considered as originals and may be filed with<br />
appropriate regulatory bodies.<br />
14. Independent Contractor Status/Tax Treatment<br />
Page 8 of 10
CONTRACTOR acknowledges and agrees that it has been engaged as an independent contractor and<br />
not as an employee. It shall be, therefore, responsible for payment of all federal, state and local taxes arising out<br />
of Its activities under this Agreement, and/or the activities of its subcontractors, agents and employees including<br />
by way of Illustration, but not limitation, federal and state income tax, Social Security tax, unemployment<br />
insurance taxes, where applicable, and business license fees, where required. CONTRACTOR understands and<br />
agrees that R2R Intermodal Inc. is not obligated or responsible to deduct any taxes which may be imposed by<br />
any governmental authority from the fees as paid to CONTRACTOR or CONTRATOR’S subcontractors, agents<br />
or employees by R2R Intermodal Inc. under this Agreement, but that any such tax obligations are the sole<br />
responsibility of CONTRACTOR. R2R Intermodal Inc. is not authorized to withhold state of federal income tax,<br />
or Social security tax upon the sums paid CONTRATOR or CONTRACTOR’S subcontractors, agents and<br />
employees.<br />
15. Invalidity<br />
In the event any provision of this Agreement shall be held to be invalid, it shall not affect the validity of<br />
the remainder of this Agreement.<br />
16. Notices<br />
Any written notice required by the terms of this Agreement shall be given either by personal delivery,<br />
by certified mall, premium overnight delivery service, telecopier or such other means as the parties shall in<br />
writing agree upon.<br />
17. Headings<br />
The headings of this Agreement’s provisions are for convenience only and shall not control or affect the<br />
meaning or construction or limit the scope or intent of any of this Agreement’s provisions. All headings shall be<br />
subordinate to the meaning of the text of the Agreement.<br />
NAME OF CONTRACTOR’S<br />
Business:<br />
__________________________________<br />
By________________________________<br />
Representative’s Signature<br />
Its _________________________________<br />
Representative’s Title<br />
R2R INTERMODAL INC.<br />
By __________________________________<br />
Authorized Agent<br />
(Attached Business Card of Contractor)<br />
Please supply Federal Employer Identification<br />
Number (FEIN)<br />
Page 9 of 10
Please supply IDES Account Number, if<br />
any _________________________________<br />
Operating Authority (if any)<br />
MC Number: _________________________<br />
Page 10 of 10
R2R Intermodal Inc.<br />
Cell Phone Policy<br />
The rule prohibits interstate commercial motor vehicle (CMV) drivers from using hand-held cell<br />
phones while driving. Under the new rule, CMV drivers will not be able to hold, dial, or reach for<br />
a hand-held cell phone, including those with push-to-talk capability. Hands-free phone use is<br />
allowed, as is the use of CB radios and two-way radios.<br />
Specifically, the rule prohibits drivers from:<br />
<br />
<br />
<br />
Using at least one hand to hold a mobile phone to conduct a voice communication;<br />
Dialing or answering a mobile phone by pressing more than a single button, and<br />
Reaching for a mobile phone in a manner that requires the driver to maneuver so that<br />
he or she is no longer in a seated, belted, driving position.<br />
Drivers will not be able to use hand-held phones while temporarily stopped due to traffic, a<br />
traffic control device, or other momentary delays, but they will be able to use them after<br />
moving the vehicle to the side of, or off, the highway and stopping in a safe location.<br />
Disciplinary Program for Cell Phone Violation<br />
1 st Violation: Written Warning / Retraining / 2 days Off<br />
2 nd Violation: Review of Records / Begin Termination of Employment<br />
Driver Signature: ___________________________________<br />
Date_____________<br />
Employer Signature:__________________________<br />
Date
Unauthorized Passengers<br />
To provide the company and employees with a clear understanding of the safety risks involved in<br />
transporting “Unauthorized Passengers” in company equipment.<br />
No employee shall transport or permit any person to be transported on/in any motor vehicle under the<br />
authority of the company, except as defined by Federal Motor Carrier Safety Regulations, Part 392.<br />
Unless specifically authorized in writing by the company whose authority the motor carrier is operated,<br />
no employee shall transport or permit any person to be transported on/in any motor vehicle other than<br />
a bus.<br />
When such authorization is issued, it shall state the name of the person to be transported, the point<br />
where the transportation is to begin and end and the date upon which such authority expires. No<br />
written authorization, however, should be necessary for the transportation of:<br />
• Employees or other persons assigned to the vehicle by the company;<br />
• Any person transported when aid is being rendered in case of an accident or emergency.<br />
Employees operating company equipment must understand and abide by the policy.<br />
The company must inform all employees operating company equipment of the “Unauthorized<br />
Passenger” policy.<br />
Employees must read and sign the acceptance document acknowledging the “Unauthorized Passenger”<br />
policy.<br />
Employees violating the “Unauthorized Passenger” policy are subject to the progressive disciplinary<br />
policy.<br />
Driver’s signature: _____________________<br />
Date: ______________
Pre-Employment Checklist<br />
Training Video<br />
As part of R2R’s employment screening process, driver must show adequate knowledge of rules,<br />
regulations, and safety procedures. For training purposes R2R provides a video for drivers that<br />
explains basic safety, driver qualifications, and how to fill out daily driving logs.<br />
I have watched and understood “CMV Driver Basics for Entry Level Training”.<br />
Driver Signature<br />
Date<br />
Test Drive<br />
Driver is required to perform the following for an R2R representative:<br />
- A full pre-trip inspection<br />
- Hook onto chassis<br />
- Back chassis up into designated area<br />
- Demonstrate filling out a daily log and POD<br />
Driver Signature<br />
Date<br />
R2R Signature<br />
Date
MOTOR VEHICLE DRIVER’S<br />
Certification of Violations/Annual Review of Driving Record<br />
CERTIFICATION OF VIOLATIONS—COMPLETED BY DRIVER<br />
Driver Name: (Please Print)<br />
Date of Employment<br />
Home Terminal(City and State) Driver’s License Number State Expiration Date<br />
I certify that the following is a true and complete list of traffic violations (other than parking violations) for which<br />
I have been convicted or forfeited bond or collateral during the past 12 months.<br />
Date of conviction Offense Location Type of motor vehicle operated<br />
If no violation are listed above, I certify that I have not been convicted or forfeited bond or collateral on account<br />
of any violation required to be listed during the past 12 months.<br />
Date of certification<br />
Driver’s Signature<br />
COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD<br />
MOTOR CARRIER: Each motor carrier shall, at least once every 12 months, require each driver it employs to<br />
prepare and fumish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations<br />
involving only parking) of which the driver has been convicted or on account of which he/she has forfeited bond or<br />
collateral during the preceding 12 months.<br />
(FMCSR 391.27)<br />
I have hereby reviewed the driving record of the above named driver in accordance with section 391.25 and find<br />
that he/she (check one):<br />
Meets minimum requirements for safe driving Is disqualified todrive a motor vehicle pursuant to Section 391.15<br />
Does not adequately meet satisfactory safe driving performance<br />
Reviewed by:<br />
Signature<br />
Date<br />
Printed Name<br />
Title<br />
Motor Carrier Name Motor Carrier Address
LEASE AGREEMENT<br />
Note: This Lease Agreement should be maintained in the Equipment during the term of the Agreement.<br />
I. I, _________________________________________________________________________ (Carrier/Registrant)<br />
Address: _______________________________________________________________________________, and<br />
___________________________________________________________________________(Equipment Owner)<br />
are parties to a written Lease Agreement (Agreement), whereby the Equipment Owner has leased to the Carrier<br />
certain motor vehicle equipment listed below, owned and controlled by the Equipment Owner, whereby the<br />
Equipment Owner is providing the Carrier as <strong>operator</strong> or <strong>operator</strong>s of the Equipment for the purpose of loading,<br />
transporting and unloading freight.<br />
II.<br />
The Original Agreement is on file at the Carrier’s General Office. A copy of this Lease Agreement and receipt for<br />
the Equipment must be carried on the Equipment as required by 49 CFR §376. Carrier verifies that the Equipment<br />
is being operated by the Carrier, pursuant to the terms of the Agreement.<br />
III.<br />
Equipment Owner/Equipment Information<br />
Name:___________________________________ Phone #: _______________________________________<br />
DBA: ____________________________________ Contact:________________________________________<br />
Address: _________________________________<br />
FEIN: __________________________________________<br />
_________________________________<br />
Year: _______ Make: ____________________ VIN: ________________________________ Unit #: __________<br />
IV.<br />
Duration of Lease Agreement and Termination<br />
The Lease Agreement shall begin on the date below and shall remain in effect until terminated by either party, giving<br />
notice to that effect. Notice may be given personally, by mail or by fax at the address or fax number shown in<br />
the Lease Agreement.<br />
MOTOR CARRIER/REGISTRANT<br />
By: ____________________________________________<br />
Date: __________________________________________<br />
EQUIPMENT OWNER<br />
By:____________________________________________<br />
Date: __________________________________________<br />
MC #:__________________________________________<br />
USDOT #: ______________________________________<br />
Printed by authority of the State of Illinois. November 2011 — 1 — VSD 683.2