TA-W68159: Commercial Road Service Application/Permit

TA-W68159 (06/2014)Page 1 of 2New York State Thruway AuthorityOffice of Traffic ManagementP.O. Box 189Albany, NY 12201-0189Phone (518) 436-2793www.thruway.ny.govCOMMERCIAL ROAD SERVICE APPLICATION/PERMITINSTRUCTIONS:• Prior to completing Sections I and II, review Notice to Permit Holder and Conditions of a Commercial Road Service Permit on Page 2.• The following items are required to be submitted with your Application:−−−a check or money order in the amount of $100.00 made payable to the "New York State Thruway Authority" (this fee is non-refundable);a CERTIFICATE OF INSURANCE (ACORD 25) which is available from your insurance provider (minimum coverage must include$1,000,000 Business Auto Liability, $1,000,000 Garage Liability, $100,000 Garagekeepers Legal Liability);NYS Workers' Compensation Board certificates of insurance for Workers' Compensation (C-105.2) and Disability Benefits (DB-120.1),as required by law; anda completed SUPPLEMENTAL INSURANCE CERTIFICATE (TA-W51343-9), available on the above website under the "Commercial" tab.−• Mail your Application packet to the address listed above for consideration. A separate Application with original signature is requiredfor each service vehicle. Photocopies not accepted.• Questions regarding insurance compliance may be directed to the Insurance Compliance Unit at (518) 436-3138.NOTE: All permits issued by the New York State Thruway Authority (Authority) are revocable at any time in the Authority's sole discretionand without cause. An approved Permit does not authorize the solicitation of business on the Thruway System, nor the use of the Authority'sname in any advertisement.Section I Applicant InformationCompany NameFederal ID No. Phone No.()-Address City State Zip Code-E-mail AddressVehicle Type and ModelVehicle Year and MakeVehicle Identification No. (VIN)License Plate No. and StateSection IIAuthorizationI declare that I,(Print or Type Name), am an owner or an agent of the above named company,and that I have the authority to execute this Application on behalf of said company. In so executing this Application, I declare that theinformation provided herein, including statements made in accompanying papers, have been examined by me and are true and correct.I understand that omissions or falsifications of statements made on this Application, including statements made in accompanying papers,may be grounds for denial or revocation of any permit without notice or cause. I further understand that all statements made are subjectto verification by the Authority or any of its agents. I give my permission for verification of statements made, which may include, but isnot limited to, insurance records, motor vehicle records, credit history, equipment inspections, on and off site procedural reviews and anyother such verification as may be deemed necessary by the Authority.Additionally, I hereby certify that the service vehicle described above is legally registered, is and/or will be marked in accordance with theThruway Authority's specifications before permit activity will commence and is equipped with required safety equipment.I certify further that all service vehicle operators are appropriately licensed to operate the service vehicle described above and that theyare aware of the Conditions of a Commercial Road Service Permit and in particular, safety equipment and procedures contained herein.Signature:Date:Section IIIFor Authority Use OnlyCertificate of Insurance on file?YesNoCertificate of Insurance approved?YesNoReviewed byNameTitleDatePermit Approved?YesNoIf "Yes," approved byNameTitleDatePermit No. Assigned Date Issued Date Expires

TA-W68159 (06/2014)Page 2 of 2COMMERCIAL ROAD SERVICE APPLICATION/PERMITNOTICE TO PERMIT HOLDERA Commercial Road Service Permit (Permit) for all Thruway System roads is required whenever a vehicle (1) enters any section of theThruway System to make repairs to a parked commercial vehicle or trailer in excess of 10,000 lbs.; or (2) removes a disabled commercialvehicle or trailer in excess of 10,000 lbs. from any section of the Thruway System; or (3) re-enters the Thruway System after exiting toobtain repair parts for a disabled commercial vehicle or trailer in excess of 10,000 lbs.The Permit is valid from August 1 to July 31 of the following year and is not prorated for any unused portion thereof or transferable to anyother vehicle. Each vehicle responding must bear its own Permit.The Permit and supporting documents must be retained in the vehicle identified herein, and exhibited upon request of the StatePolice or Thruway Authority personnel. The issued medallion must be affixed as required under the CONDITIONS FOR COMMERCIALROAD SERVICE PERMIT MEDALLION PLACEMENT (TA-W68159A). This Application will be considered a valid Permit once it has beensigned with an original blue ink signature or stamp by the Bureau of Traffic Management.The Permit medallion is the sole property of the New York State Thruway Authority and must be removed and/or returned upon demandwithout the necessity of showing prior notice or cause.In accepting the Permit, the permittee agrees to assume responsibility and liability for any and all damages to persons and/or propertyresulting from or in any way connected to the operation of the permittee's vehicle or combination of vehicles by permittee, itsagents and/or employees, and to save the New York State Thruway Authority harmless there from.CONDITIONS OF A COMMERCIAL ROAD SERVICE PERMITTraveling the Thruway with a disabled vehicle in towThis Permit is not valid unless the towing vehicle has an intact tractor, straight truck, or bus in tow and is properly equipped withemergency warning lights. The combination of the towing and disabled vehicle must also be considered safe for travel on the ThruwaySystem by Thruway Authority and State Police personnel. Towing of tractor-trailer combinations is specifically prohibited, except whenremoving a combination unit to the first interchange (exit) in the same direction of travel as the disablement.Roadside ServicingThis Permit is not valid unless the servicing facility is within 100 miles of the disabled vehicle and the repairs can be completed and thevehicle removed within four (4) hours of the reported disablement. All U-turns on the Thruway System are prohibited except whenapproved and supervised by a member of the State Police or an employee of the Thruway Authority. Towing is permitted from theright shoulder only.Under no circumstances does a Permit allow for towing at accident scenes, for towing or servicing when the vehicle has been deemed tobe a hazard to the safe operation on the Thruway System, deemed to be abandoned, for vehicle or cargo recovery activities or for anyother such reason as may be deemed by the Thruway Authority without the necessity of prior notice or showing of cause. Any vehicledeemed a hazard due to accident, location or abandonment may only be towed by the appropriate Thruway Authorized Garage.Examples of allowed services under a Commercial Road Service Permit are: fuel filter replacement, brake adjustment, tire service,tractor swaps, fuel calls, light mechanical repair and/or towing from the right shoulder only. This, however, does not authorize servicewhere there is interference to normal traffic flow or the occupancy of a traffic lane is necessary.Completion of the CERTIFICATE OF INSURANCE (ACORD 25), SUPPLEMENTAL INSURANCE CERTIFICATE (TA-W51343-9), and NYSWorkers' Compensation (C-105.2) and Disability Benefits (DB-120.1) certificates of insurance are mandatory and must be on file withthe Thruway Authority prior to the validation of a Permit. The Permit is deemed revoked upon any lapse in insurance coverage and alloperations under said Permit must cease without notice. Upon resumption of insurance coverage a new Permit must be obtained andproper fee paid, with such additional proof of insurance as may be deemed appropriate by the Thruway Authority to satisfy coveragerequirements.Safety Equipment and ProceduresAll commercial road service providers' vehicles must be equipped with working emergency warning lights and flares, reflectors, flaps andcones which must be placed at the scene of a disabled vehicle in the direction of approaching traffic as follows: one at the disabledvehicle, one at 250 feet and a third at 500 feet from the disabled vehicle. Indicators shall be more numerous and placed at greaterdistances as weather, road conditions or other circumstances so require. Flares and reflectors must be used during the period from ½hour before sunset until ½ hour after sunrise, or as conditions require and be visible at a distance of not less than 1,000 feet from thescene of the disabled vehicle. Service vehicle operators are required to wear ANSI Class 3 high visibility safety clothing at all times.Any violations of herein stated notices and conditions, or such notices or conditions deemed to be in the best interest of the safetyof the Thruway Authority's operations, may result in suspension or revocation of the Permit and forfeiture of fees, and the liability foradministrative costs by the permittee, without prior notice or demonstration of cause.