Revised - Landstar

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URGENT * URGENT * URGENT REQUEST FOR CERTIFICATE OF INSURANCE To: ____________________________________________________ Insurance Agent Insured: ____________________________________________________ Carrier Company Name (include your name and phone number) Re: PROVIDE A CERTIFICATE OF INSURANCE TO LANDSTAR Dear Insurance Agent: As your carrier client I am requesting that you provide Landstar a Certificate of Insurance per the underlined details below: 1. Landstar requires proof of insurance coverage for Auto and Cargo • Auto Liability of $1,000,000 minimum coverage (U.S. Funds) • Motor Truck Cargo of $100,000 minimum coverage (U.S. Funds) – extent of coverage as indicated in brokerage agreement. Please specify whether cargo coverage is All Risk or Broad Form Trailer Interchange of $25,000 is required for Landstar-owned equipment usage (Any Leased and or Non-Owned trailers used by CARRIER shall be covered under CARRIER’S insurance policy with the same force and effect as if owned and scheduled on CARRIER’S policy). 2. If cargo policy is subject to specific Target Commodity limitations, Unattended and/or Unattached restrictions less than 72 hours then please include a brief comment in the description area of the certificate regarding coverage. 3. Certificate must have Issue/Effective/Expire dates, Policy numbers, Deductible amount for cargo and contain a Notice of Cancellation of no more than 30 days. 4. Certificate Holder or Additional Insured should be listed as: Landstar System, Inc. and each of its wholly-owned subsidiary companies P. O. Box 19137, Jacksonville, FL 32245 5. The certificate MUST BE SIGNED by an Authorized Representative. Call Landstar directly at 800-872-9515 if you have any questions regarding the specific items mentioned above. Landstar checks for the current A.M. Best Ratings for insurance companies and accepts only a B+ or better rating. PLEASE FAX signed certificate to 800-235-1071. Thank you! Sincerely, Your Carrier Client QUALTP-Ins Request Ltr-US Revised: 04/30/09 Page 2
Form W-9 (For Landstar Use Only) Department of the Treasury Internal Revenue Service Print or type. See specific Form W-9 instructions at www.IRS.gov. Request for Taxpayer Identification Number and Certification Individual Name, Incorporated Name (This line cannot be left blank; refer to your income tax return**) Business Name, Doing Business As Name (This line can remain blank if Individual has no registered Trade name) Check appropriate box: Individual/ Sole proprietor Corporation Partnership Limited liability company, Enter the tax classification (C=corporation, P=partnership) ►______ Other ► D=Disregarded QUALTP-Form W9-US Revised: 04/30/09 Page 3 Fax form to the requester. Do not send to the IRS. Exempt payee Address (number, street, and apt. or suite no.) Requestor’s name and address (optional) Landstar System, Inc. P. O. Box 19137, Jacksonville, FL 32245 City, state, and ZIP code Tel. 800-872-9515 Fax. 800-235-1071 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) INSTRUCTIONS: enter your Tax Identification Number in either the SSN box or FID box PLEASE PROVIDE ONLY ONE NUMBER ** USE THE SAME NUMBER YOU USE TO REPORT YOUR INCOME TO THE IRS **SOLE PROPRIETORS MUST GIVE THEIR INDIVIDUAL NAME ON LINE ONE ABOVE IMPORTANT: the top two lines for entering your Name/Company Name/DBA should be filled out exactly as seen on your income tax return. Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. Sign Here Authorized Signature ► Date ► This form is considered invalid if not signed and dated. Purpose of Form A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN your are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. In 3 above, if applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income. Note: per the IRS, if a requester gives you a form other than the actual published Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to the IRS official Form W-9. S S N F I D 1 1 │ │ ┼ │ ┼ │ │ │ │ ┼ │ │ │ │ │ │ For federal tax purposes, you are considered a person if you are: • An individual who is a citizen or resident of the United States, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, or • Any estate (other than a foreign estate) or trust. See Regulations sections 301.7701-6(a) and 7(a) for additional information. Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Note. The entirety of IRS Form W-9 can be viewed at www.IRS.gov. This is a replicate of Form W-9 for the purpose of Landstar System, Inc. to request your TIN. OR
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Revised - Landstar

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