owner-operator

MEMBERSHIP APPLICATION
APPLICANT:
MR.
MRS.
MS.
LAST FIRST MIDDLE
ADDRESS:
(PHYSICAL) STREET
APT/STE CITY STATE ZIP
ADDRESS:
(MAILING)
STREET
APT/STE
CITY
STATE
ZIP
PHONE #:
( )
HOME CELL OTHER
PHONE #:
(
)
HOME CELL OTHER
E-MAIL:
@
NO EMAIL
DO YOU OWN YOUR OWN COMPANY?
YES
NO
IF “YES”, ENTER NAME HERE:
I HEREBY APPLY FOR MEMBERSHIP IN THE NATIONAL ASSOCIATION OF INDEPENDENT TRUCKERS, LLC (“NAIT”)
AND AGREE TO PAY MONTHLY MEMBERSHIP DUES DISCLOSED AT www.naitusa.com.
I UNDERSTAND MEMBERSHIP IS NONTRANSFERABLE.
SUBMISSION OF THIS APPLICATION FOR MEMBERSHIP AUTHORIZES NAIT AND ITS AFFILIATED BENEFIT PROVIDERS TO CONTACT ME
OR MY COMPANY BY MAIL, PHONE, FAX OR E-MAIL REGARDING NAIT MEMBERSHIP AND MEMBER BENEFITS.
SIGNATURE:
DATE:
RETURN TO:
MAIL: PO BOX 901606, KANSAS CITY, MO 64190
E-MAIL: MemberBenefits@NAITUSA.com
FAX: (816) 713-1333
018019 3/15
FOR ADDITIONAL INFORMATION ON YOUR TOTAL BENEFIT PACKAGE VISIT www.naitusa.com OR CALL (800) 821-8014
Follow us on Twitter: @naitusa

Motor Vehicles Driver’s
CERTIFICATION OF COMPLIANCE
WITH DRIVER LICENSE REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in
intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport
more than 15 people, or transports hazardous materials that require placarding.
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle
weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require
placarding.
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some
requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are
as follows:
1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one
motor vehicle operator’s license.
If you have more than one license, keep the license from your state of residence and return the additional
licenses to the states that issued them. DESTROYING a license does not close the record in the state that
issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record
by notifying the state of issuance that you no longer want to be licensed by that state.
2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:
Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify
your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In
addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking),
you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your
license (If the violation occurs in a state other than the one which issued your license). The notification to
both the employer and state must be in writing.
The following license is the only one I will possess:
Driver's License No.
State
Exp. Date
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.
Driver's Name (Printed):
Driver’s Signature:_______________________________________ Date________________________
Notes:
(This form is not required for DOT compliance)
90-F 1617
© 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
COMPANY NAME: ________________________________________________________________
ADDRESS:____________________________________________
ZIP _____________
PHONE NO.: ______________________________________________________________________
In consideration for my being considered for employment, I, ____________________________ ,
hereby give my consent to and authorize ________________________________________________
the employer, to perform any testing or medical procedures necessary to determine the presence of
alcohol or drugs in my body.
I further give my consent to release to __________________________________________________
or its designated agents, the results of any medical test performed, including any test or medical
procedures to determine the level or presence of alcohol or drugs.
I realize that my refusal to sign this form constitutes a violation of the employer's stated policy, and
for that refusal, I will not be considered for, and knowingly waive any possibility of employment.
I understand this consent and release shall be valid for my length of employment and that a copy of
this consent form shall be valid as an original.
_______________________________________
Applicant Signature
_________________________
Date
_______________________________________
Witness Signature
_________________________
Date
(Suggest you have your attorney look at and approve before using)

PRE-EMPLOYMENT URINALYSIS
NOTIFICATION
The Federal Motor Carrier Safety Regulations, Section 391.103 Pre-Employment Testing Requirements, apply
to driver applicants of this company.
391.103 PRE-EMPLOYMENT TESTING REQUIREMENTS.
(a) A motor carrier shall require a driver-applicant who the motor carrier intends to hire or use pre-qualification
condition.
(b) A driver-applicant shall submit to controlled substance testing as a pre-qualification condition.
(c) Prior to collection of the urine sample under FMCSR 391.107 of this subpart, a driver-applicant shall be
notified that the sample will be tested for the presence of controlled substances.
As a condition of employment, I agree to the urine sample collection and controlled substance testing.
I understand a positive test for controlled substances based on the Urinalysis Test will medically disqualify me
from the operation of a commercial motor vehicle for this company.
The Medical Review Officer will maintain the results of the Urinalysis Test. Negative and Positive results will
be reported to the company.
My written authorization is required for the Urinalysis Tests to be given to other parties.
I have read and understand the above conditions for the Pre-Employment Urinalysis Notification.
_______________________________
Applicant’s Name
_______________________________
Applicant’s Signature
______________________
Date
Witnessed By:
_______________________________
Company Representative
______________________
Date

Name
DRIVER'S
APPLICATION FOR EMPLOYMENT
Company
Address
City State Zip
(answer all questions-please print)
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions
without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other
protected group status.
Date of Application
Position Applied for
List your addresses of residency for the past 3 years.
Current Address
Previous
Addresses
Street
State Zip Code Phone yr./mo
City
How Long?
How Long?
Street City State & Zip Code yr./mo
How Long?
Street City State & Zip Code yr./mo
How Long?
Street City State & Zip Code yr./mo
Do you have the legal right to work in the United States?
Date of Birth
(Required for Commercial Drivers)
Have you worked for this company before?
Can you provide proof of age?
Where?
Dates: From To Rate of Pay Position
Reason for leaving
Are you now employed?
Who referred you?
If not, how long since leaving your last employment?
Rate of pay expected?
Have you ever been bonded?
Have you ever been convicted of a felony?
Name of bonding company?
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all
circumstances will be considered.
Emergency Contact Person
NAME RELATIONSHIP PHONE NUMBER
© Copyright 1998 J. J. KELLER & ASSOCIATES, INC., Neenah, WI • USA
This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal,
accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form,
15F (Rev. 5/02) 691
(800) 327-6868 • Printed in the United States
or any decision made by an employer which may violate local, state, or federal law.

EMPLOYMENT HISTORY
All applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List
complete mailing address, street number, city, state and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on
those employers for whom the applicant operated such vehicle.
(Note: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
EMPLOYER
DATE
NAME
ADDRESS
CITY STATE ZIP CODE
FROM
POSITION HELD
SALARY/WAGE
TO
CONTACT PERSON PHONE #
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO
REASON FOR LEAVING
EMPLOYER
DATE
NAME
ADDRESS
CITY STATE ZIP CODE
FROM
POSITION HELD
SALARY/WAGE
TO
CONTACT PERSON PHONE #
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO
REASON FOR LEAVING
EMPLOYER
DATE
NAME
ADDRESS
CITY STATE ZIP CODE
FROM
POSITION HELD
SALARY/WAGE
TO
CONTACT PERSON PHONE #
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO
REASON FOR LEAVING
EMPLOYER
DATE
NAME
ADDRESS
CITY STATE ZIP CODE
FROM
POSITION HELD
SALARY/WAGE
TO
CONTACT PERSON PHONE #
DID YOU DRIVE A VEHICLE REQUIRING A CDL? YES NO
REASON FOR LEAVING
* Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle
used to transport hazardous materials in a quantity requiring placarding.
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
LAST ACCIDENT
DATES
NATURE OF ACCIDENT
(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES
NEXT PREVIOUS
NEXT PREVIOUS
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION
DATE CHARGE PENALTY
(ATTACH SHEET IF MORE SPACE IS NEEDED)
EDUCATION
CHECK HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4
LAST SCHOOL ATTENDED
(NAME)
(CITY)
EXPERIENCE AND QUALIFICATIONS - DRIVER
DRIVER
STATE LICENSE NO. TYPE EXPIRATION DATE
LICENSES
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO
B. Has any license, permit or privilege ever been suspended or revoked? YES NO
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS BELOW
DRIVING EXPERIENCE CHECK ALL THAT APPLY
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC.)
FROM
DATES
TO
APPROX. NO. OF MILES
(TOTAL)
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR – TWO TRAILERS
MOTORCOACH – SCHOOL BUS
OTHER
LIST STATES OPERATED IN FOR LAST FIVE YEARS
LIST STATES OPERATED IN FOR LAST FIVE YEARS
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
PAGE 3 15F (Rev. 5/02) 691

EXPERIENCE AND QUALIFICATIONS – OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES, TRAINING or CERTIFICATIONS THAT YOU MAY HAVE OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
TO BE READ AND SIGNED BY APPLICANT
This certifies that this application was completed by me, and that all entries on it and information in it are true and
complete to the best of my knowledge.
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history
and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries
regarding medical history will be made only if and after a conditional offer of employment has been extended.) I
hereby release employers, schools, health care providers and other persons from all liability in responding to
inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s)
may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the
Company.
___________________________________
DATE
APPLICANT HIRED
DATE EMPLOYED
DEPARTMENT
___________________________________________
APPLICANTS SIGNATURE
PROCESS RECORD
REJECTED
POINT EMPLOYED
CLASSIFICATION
(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
THIS SECTION TO BE FILLED IN BY RESPONSIBLE
OFFICER OR COMPANY REPRESENTATIVE
1.APPLICATION
2.INTERVIEW
3.PAST EMPLOYMENT
4.WRITTEN EXAM
5.ROAD TEST
6.CRIMINAL AND TRAFFIC
CONVICTIONS
SUPERIOR GOOD FAIR BELOW AVERAGE POOR WRITTEN RECORD ON FILE
FROM:
DATE:
SIGNATURE OF INTERVIEWING OFFICER ________________________________________________________________
TRANSFERS
TO:
FROM:
TO:
DATE:
REASON FOR TRANSFER:
REASON FOR TRANSFER:
FROM:
TO:
FROM:
TO:
DATE:
DATE:
REASON FOR TRANSFER:
REASON FOR TRANSFER:
TERMINATION OF EMPLOYMENT
DATE TERMINATED
DEPARTMENT RELEASED FROM
DISMISSED VOLUNTARILY QUIT OTHER
TERMINATION REPORT PLACED IN FILE
SUPERVISOR
PAGE 4 15F (Rev. 5/02) 691

Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0047; Expires 08/31/12
Form I-9, Employment
Eligibility Verification
Read instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT
specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a
future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)
Print Name: Last First Middle Initial Maiden Name
Address (Street Name and Number) Apt. # Date of Birth (month/day/year)
City State
Zip Code Social Security #
I am aware that federal law provides for
imprisonment and/or fines for false statements or
use of false documents in connection with the
completion of this form.
Employee's Signature
I attest, under penalty of perjury, that I am (check one of the following):
A citizen of the United States
A noncitizen national of the United States (see instructions)
A lawful permanent resident (Alien #)
An alien authorized to work (Alien # or Admission #)
until (expiration date, if applicable - month/day/year)
Date (month/day/year)
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
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.
Preparer's/Translator's Signature
Print Name
Address (Street Name and Number, City, State, Zip Code)
Date (month/day/year)
Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR
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
expiration date, if any, of the document(s).)
List A
OR
List B
AND
List C
Document title:
Issuing authority:
Document #:
Expiration Date (if any):
Document #:
Expiration Date (if any):
CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that
the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on
(month/day/year)
and that to the best of my knowledge the employee is authorized to work in the United States. (State
employment agencies may omit the date the employee began employment.)
Signature of Employer or Authorized Representative
Print Name
Title
Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)
Date (month/day/year)
Section 3. Updating and Reverification (To be completed and signed by employer.)
A. New Name (if applicable)
B. Date of Rehire (month/day/year) (if applicable)
C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.
Document Title:
Document #:
Expiration Date (if any):
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
document(s), the document(s) l have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Date (month/day/year)
Form I-9 (Rev. 08/07/09) Y Page 4

LISTS OF ACCEPTABLE DOCUMENTS
All documents must be unexpired
LIST A LIST B LIST C
Documents that Establish Both
Identity and Employment
Authorization
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien
Registration Receipt Card (Form
I-551)
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machinereadable
immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. In the case of a nonimmigrant alien
authorized to work for a specific
employer incident to status, a foreign
passport with Form I-94 or Form
I-94A bearing the same name as the
passport and containing an
endorsement of the alien's
nonimmigrant status, as long as the
period of endorsement has not yet
expired and the proposed
employment is not in conflict with
any restrictions or limitations
identified on the form
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association
Between the United States and the
FSM or RMI
OR
Documents that Establish
Identity
1. Driver's license or ID card issued by
a State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height,
eye color, and address
2. ID card issued by federal, state or
local government agencies or
entities, provided it contains a
photograph or information such as
name, date of birth, gender, height,
eye color, and address
3. School ID card with a photograph
4. Voter's registration card
5. U.S. Military card or draft record
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
9. Driver's license issued by a Canadian
government authority
For persons under age 18 who
are unable to present a
document listed above:
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
AND
Documents that Establish
Employment Authorization
1. Social Security Account Number
card other than one that specifies
on the face that the issuance of the
card does not authorize
employment in the United States
2. Certification of Birth Abroad
issued by the Department of State
(Form FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
5. Native American tribal document
6. U.S. Citizen ID Card (Form I-197)
7. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
8. Employment authorization
document issued by the
Department of Homeland Security
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)
Form I-9 (Rev. 08/07/09) Y Page 5

Contract Driver
NAIT Association Program Insurance Application
Applicant Name: Mr. Mrs. Ms.
Last First Middle
Address:
Street/PO Box Apt City State Zip
Social Security #: Date of Birth: Phone:
CDL #: CDL State: What do you haul?
Fleet Owner Name & Address: __________________________________________________________________________
__________________________________________________________________________________________________
Insurance services provided by TransGuard General Agency, Inc. (“TGA”); In California, doing business as TransGuard
General Insurance Agency; In Utah, doing business as TransGuard General Insurance Agency, Inc. If you need coverage
that is not addressed in this application, please contact TransGuard General Agency, Inc. at (800) 821-8014 for assistance.
OCCUPATIONAL ACCIDENT
Do you want to purchase Occupational Accident coverage for yourself? Yes* No
*If yes, please complete the following information:
How is your income reported: 1099 W-2 Height:_____Feet _____Inches Weight:______
Please name a beneficiary for the payment of accidental death benefits. (Accidental death benefits are payable to
your surviving spouse or dependent children, subject to the terms and conditions of this coverage. The beneficiary
designation requested only applies when benefits are payable and you do not have a spouse or dependent children
surviving.)
Name of Beneficiary Address (Street/City/State/Zip) Relationship
Have you been injured in a work-related accident during the past 36 months? Yes No
Date of Accident/Injury: _________________________________________________________________________
Explanation of Accident/Injury: ___________________________________________________________________
____________________________________________________________________________________________
Treatment Received: __________________________________________________________________________
Have you received medical treatment for a health-related condition in the past 36 months? Yes No
Describe health related condition and treatment received: ______________________________________________
____________________________________________________________________________________________
Are you presently taking any prescription medications? Yes No
List medications and what conditions they are used to treat: ____________________________________________
____________________________________________________________________________________________
Do you have any health restrictions or limitations on the type of work you can perform? Yes No
Describe restrictions and limitations: _______________________________________________________________
____________________________________________________________________________________________
Do you have a disability rating? Yes* No
*If yes, give percentage: %_________ Disabled area:_____________________________________________________
What caused the disability? _____________________________________________________________________
When this coverage is provided, you will be insured under the Occupational Accident plan elected by your fleet
owner’s motor carrier as satisfying their coverage requirements or the plan you elect if billed direct pay. You are
also selecting Non-Occupational Accident Coverage with this purchase if your fleet owner’s motor carrier requires
such coverage on the date of application. If Occupational Accident Coverage for a Helper / Co-driver or Partner is
needed, a separate supplemental application must be completed. Contact TransGuard General Agency, Inc. for
assistance.
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 1 of 4
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014

WORKERS’ COMPENSATION
(Excludes sole-proprietor and partner, this coverage is for your casuals/helpers only)
Do you want to purchase coverage for your casuals/helpers? Yes No
Your FEIN / State Tax ID #: _________________________
COMMERCIAL BUSINESS AUTO
Do you want to purchase Physical Damage Coverage? Yes No
Which Comprehensive/Collision Deductible? $250 $500 $1000 $2500
Stated Amount: $ _____________
Tractor Trailer Other: _______________________________________________________________________
_________ _________________________________________ _____________________________________
Year Manufacturer/Model/Gross Weight VIN#
__________________________ ___________________________________________________________________
Loss Payee (lien holder/lessor) Loss Payee Address
NAIT MEMBERSHIP
I understand that I must be a member of the National Association of Independent Truckers (“NAIT”) in order to participate in
its insurance programs. If I am not currently a member, I will apply for membership. I may become and remain a member of
NAIT without the purchase of NAIT sponsored insurance.
POLICY TERMS AND CONDITIONS
Coverage applied for under the NAIT insurance program is subject to all the terms, conditions and limitations of the policy
providing the coverage requested.
PAYMENT TERMS: I understand that the cost of this insurance is my sole obligation and responsibility, and I agree
that I will pay upon demand or at any time my account remains unpaid, any amount due and owing. I also understand that if
my insurance is canceled my deposit premium will be used to cover my outstanding premium. If the motor carrier to whom
my fleet owner is under contract has agreed to settlement deduction arrangements for the payment of premium, I hereby
APPOINT that motor carrier as my agent for receipt of NAIT Program billing notices and AUTHORIZE them to make
deductions from my account equal to the cost of NAIT membership dues, benefits and insurance premiums and to remit
same as required on my behalf. I also authorize the motor carrier named on page 4 of this application or on my Evidence of
Coverage, if changed, to remit any deposit premium and/ or membership dues required for participation in NAIT’s insurance
programs. Deposit premium is fully refundable upon termination of coverage if my account is current and in good standing. I
understand there is a one-month deposit charge for NAIT membership dues and a one month deposit premium charge for all
insurance coverages, except Workers’ Compensation. For Workers’ Compensation, a state mandated minimum charge, per
policy, is applicable.
AGREEMENTS
I certify that I am DOT qualified and that I have complied with all applicable DOT requirements. I am not now, nor will I
become, an employee of any motor carrier or fleet owner while any insurance provided through an NAIT program is in force.
I authorize the release to TGA, its affiliated insurers and their representatives, if necessary: 1) all insurance documents
related to me and/or my insured equipment; 2) my current Motor Vehicle Report (MVR), including updates as needed; 3)
applicable medical records; 4) any test results in accordance with DOT regulations; 5) a copy of my current equipment lease
agreement(s), if any; and 6) a copy of my independent contractor agreement with my fleet owner. I understand this
information may be used for purposes of evaluating my application for insurance. I authorize the motor carrier listed on my
Evidence of Coverage to request cancellation of my coverage whose premium is paid by settlement deduction arrangements
when I am no longer under contract to my fleet owner or when my fleet owner is no longer under contract to that motor
carrier. I understand NAIT, as group policyholder, has authority to execute and cancel all group coverage. I knowingly reject
statutory Workers’ Compensation coverage when opting for Occupational Accident coverage, if required by state law.
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 2 of 4
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014

AGREEMENTS (CONTINUED)
Applicable To Occupational Accident coverage only: I further understand and agree that as an independent contractor
and in choosing this Occupational Accident coverage, I am not able to file nor otherwise assert any claim for statutory
Workers’ Compensation benefits against my fleet owner, my fleet owner’s motor carrier and/or any insurers or other
companies related to such entities. I further agree to indemnify and forever hold harmless NAIT, my fleet owner, my fleet
owner’s motor carrier and/or any insurers or other companies related to any of the foregoing entities of and from any and all
claims that may be made by me or by anyone else on my behalf for statutory Workers’ Compensation benefits.
A credit report or other investigative report about me may be requested in connection with this application for insurance and
subsequent renewals. Any information about me or which I have provided about anyone will be treated confidentially.
However, this information, as well as other non-public personal or privileged information subsequently collected, may, under
certain circumstances, be disclosed without prior authorization to non-affiliated third parties. Information may be shared with
affiliated companies for such purposes as claims handling, servicing, underwriting and insurance marketing. I have the right
to see personal information collected about me, and I have the right to correct any information which may be wrong. A
description of TGA’s information practices, and my rights regarding information TGA collects may be obtained by contacting
TGA.
I certify the information that I have provided in this application is true, complete and accurately recorded to the best of my
knowledge and belief. I understand this information will be used to apply for insurance coverage on my behalf. If approved,
this application will be attached to and made a part of each policy providing the coverage requested. I certify that I have
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
laws and/or regulations regarding work eligibility. I understand that the giving of any inaccurate, false, or misleading
information on this application may result in rejection of this application and the denial of benefits under any and all
insurance coverage for which I have applied.
FRAUD WARNINGS
Fraud Warning applicable to residents of all states except those listed below and Nebraska: Any person who knowingly and with
intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially
false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.
ADDITIONAL STATE SPECIFIC FRAUD LANGUAGE
IN ARKANSAS, LOUISIANA AND MARYLAND - Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
IN CALIFORNIA - For your protection California law requires the following to appear on this form: Any person who knowingly presents a
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.
IN COLORADO - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to
a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
IN DISTRICT OF COLUMBIA – Warning: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant.
IN FLORIDA - Any person who knowingly and with intent in injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
IN HAWAII - For your protection, Hawaii law requires you to be informed that any person who presents a fraudulent claim for payment of
a loss or benefit is guilty of a crime punishable by fines or imprisonment, or both.
IN KENTUCKY – Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
IN MAINE - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
INITIAL/DATE:________________
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 3 of 4
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014

ADDITIONAL STATE SPECIFIC FRAUD LANGUAGE (CONTINUED)
IN NEW JERSEY - Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties
IN NEW MEXICO - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
IN NEW YORK - Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another
to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department
of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil
penalty not to exceed $5,000 and the value of the subject motor vehicle or stated claim for each violation.
IN OHIO - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty of insurance fraud.
IN OKLAHOMA - Warning – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
IN OREGON - Any person who knowingly and with intent to defraud any insurance company or another person files an application for
insurance or statement of claim containing any materially false information may be subject to prosecution for insurance fraud.
IN PENNSYLVANIA – Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing
any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of
a fine of up to $15,000.
IN TENNESSEE, VIRGINIA AND WASHINGTON - It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
I UNDERSTAND AND AGREE THAT COVERAGE REQUESTED IN THIS APPLICATION WILL NOT BE AFFORDED
UNTIL THIS APPLICATION IS SUBMITTED AND I AM APPROVED. I CERTIFY AND REPRESENT THAT I HAVE READ
AND UNDERSTAND THIS APPLICATION USING TRANSLATION SERVICES AS NEEDED AND THAT THE
INFORMATION I HAVE PROVIDED AND THE REPRESENTATIONS I HAVE MADE HEREIN ARE TRUE AND CORRECT.
I certify that I am an independent contractor and not an employee of my fleet owner or my fleet owner’s motor carrier.
APPLICANT SIGNATURE
DATE
MOTOR CARRIER NAME/TERMINAL LOCATION
UNIT NUMBER
I certify that I am an independent contractor and not an employee of any motor carrier and that the applicant is not my
employee but is an independent contractor working on my behalf.
FLEET OWNER SIGNATURE
DATE
____________________________________
018050 07/15 Mail to: TransGuard/NAIT Association Program, PO Box 901606, Kansas City, MO 64190-1555 4 of 4
Or, Fax to (816) 713-1333 www.transguard.com Phone: (800) 821-8014

!
Direct Deposit Authorization Form
Please print and complete ALL the information below.
Name:
Address:
City, State, Zip:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Name of Bank:
Account #:
9-Digit Routing #:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Amount: $ ______________ _______% or Entire Paycheck
Type of Account: Checking Savings
Please attach a voided check for each bank account to which funds should be deposited.
__________________________ is hereby authorized to directly deposit my pay to the account
listed above. This authorization will remain in effect until I modify or cancel it in writing.
Employee Signature: ___________________________
Date: ______________________

INDEPENDENT CONTRACTOR AGREEMENT
FOR OWNER-OPERATOR
THIS AGREEMENT is made this
in the State of ILLINOIS by and between
R2R Intermodal Inc. a regulated for hire motor carrier, an IL corporation and
("CONTRACTOR"), as follows:
WHEREAS, R2R Intermodal Inc is engaged in business to provide trucking service for different customers and
intends to contract with CONTRACTOR in the performance of certain tasks;
WHEREAS, between R2R Intermodal Inc. principal place of business is located at the following address: 2636
West Foster Ave Chicago, IL 60625
WHEREAS, CONTRACTORS principal place of business is located at the following address:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
WHEREAS, CONTRACTOR is doing business at a (check one):
Partnership Sole Proprietorship Corporation
NOW THEREFORE, in consideration of the mutual covenants herein contained the sufficiency of which is
acknowledged, it is agreed as follows:
1. Effective Date
This agreement shall become effective upon signing by both parties and shall remain in effect for one (1)
year from date of signing, and shall automatically renew for additional like periods, not to exceed a total of
three (3) years unless: sooner canceled.
2. Termination
This Agreement may be terminated:
A. Without cause, upon either party giving the other thirty (30) days prior written notice; or
B. For cause, immediately, upon material breach of any term of this Agreement by either of the parties.
C. CONTRACTOR has the right to terminate this Agreement under the terms stated herein. In accordance
with Section 212.1 (a) (2) of the Illinois Unemployment Insurance Act, following termination,
CONTRACTOR has the right to perform the same or similar services, on whatever basis and whenever
CONTRACTOR chooses, for persons or entities other than R2R Intermodal Inc. except as limited by
the requirements promulgated by regulations of the Federal Highway Administration Illinois commerce
Commission, or any other regulatory body having jurisdiction.
3. Registration/Licensing of R2R Intermodal Inc.
A. Such as contemplated by Section 212.1 (a)(1) of the Illinois Unemployment Insurance Act R2R
Intermodal Inc. is a for hire motor carrier authorized to transport property pursuant to licenses issued by
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the Federal Highway Administration (successor in interest to the Interstate Commerce Commission) and
other federal and state operating authorities and licenses.
B. R2R Intermodal Inc. will use said Equipment in its business as a motor carrier, under its various
certificates or permits which it now holds or which it may subsequently acquire, where such are
required. Such Equipment furnished to R2R Intermodal Inc. shall be exclusively used in R2R
Intermodal Inc. business to the extent required by all applicable laws and regulations. Said Equipment
shall, during the term of this Agreement, be under R2R Intermodal Inc. exclusive possession, use and
control, to the extent contemplated by and required by all applicable federal and state laws and
regulations relating to the operation of leased motor vehicle equipment by motor carriers R2R
Intermodal Inc. assumes full responsibility for the operation of said Equipment as to all third parties and
the public at large. However, this shall no way modify, alter or affect CONTRACTOR’S status as an
Independent Contractor, and not an employee of R2R Intermodal Inc. Nothing in this Agreement shall
be deemed as a delegation of R2R Intermodal Inc. duties as a common or contract or contract carrier to
CONTRACTOR in so far as the public or any governmental or regulatory body may be concerned. The
terms of this Agreement are merely an assignment and distribution of various costs arising out of the
operations to be conducted pursuant to this Agreement, between the parties to this Agreement.
4. Ownership of Equipment
In accordance with Section 212.1(a) (4) of the Illinois Unemployment Insurance Act. CONTRACTOR
declares that it holds title to (or is otherwise legally entitled to lease) said Equipment and does lease to R2R
Intermodal Inc. The Equipment described in Appendix “A,” attached to this Agreement and made a part hereof.
That equipment is referred to in this Agreement as “Equipment.”
5. Name and Address on CONTRACTOR’S EQUIPMENT
In accordance with Section 212.1 (a) (6) of the Illinois Unemployment Insurance Act, CONTRACTOR
agrees to display its business name and address on all Equipment covered by this Agreement. Any such display
of business name and address shall comply with applicable law and with the rules and regulations of the United
States Department of Transportation.
6. Availability and Scheduling
In accordance with Section 212.1 (a) (3) of the Illinois Unemployment Insurance Act, CONTRACTOR is
not required by R2R Intermodal Inc. to perform service or be available to perform services at specific times or
according to a schedule or for a number of hours specified by R2R Intermodal Inc. However, pickup or delivery
times specified by a shipper, receiver, broker, or other party that owns or controls a shipment shall not be deemed
“specified” by.
7. Licensing and Operating Costs
A. CONTRACTOR’s Costs, In accordance with Section 212.1 (a) (5) of the Illinois Unemployment
Insurance Act, CONTRACTOR shall pay all costs of licensing and operating the Equipment (except
when federal or state law or regulation requires R2R Intermodal Inc to pay), and no costs of such
licensing or operating shall be separately reimbursed by any other person or entity. Also,
CONTRACTOR agrees to pay a reasonable rental, to be negotiated between the parties, If
CONTRACTOR desires to rent trailer(s). CONTRACTOR agrees that the Equipment described herein
will be kept and maintained in first-class condition and repair at CONTRACTOR’S sole expense.
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CONTRACTOR agrees to pay all of the expenses incurred in operating the Equipment which is the
subject of this Agreement, without limitation, including, but not limited to, those items enumerated in
49 C.F.R. §376.12(e) cost of fuel, fuel taxes, empty miles, permits of all types, tolls, ferries, detention,
accessorial services, base plates and licenses, and the unused portion of such items]. Upon failure of
CONTRACTOR to make such payments, R2R Intermodal Inc. may avail itself of any remedies
described in Paragraph (2) herein or elsewhere in this Agreement.
B. SAFETY COMPLIANCE, CONTRACTOR warrants that the Equipment leased herein complies with
all of the required safety rules and complies with all rules and regulations of the United States
Department of Transportation, and any and all federal, state or local regulatory bodies having
jurisdiction over the operation of said Equipment, and that all taxes, of any nature, assessable against the
leased Equipment or its operation have been paid. All costs incurred in connection with causing the
Equipment leased hereunder to comply with said rules and regulations and any loss, damage or expense
of any nature, whatsoever, which shall result from CONTRACTOR’S failure to ensure such
compliance, shall be borne by CONTRACTOR. Upon failure of CONTRACTOR to promptly and
immediately ensure such compliance and pay such costs or expenses R2R Intermodal Inc. pay, at its
exclusive option, effect such compliance, pay such costs or expenses, and deduct the amount of such
payment, together with any administrative expenses incurred in so doing, from any monies due of which
may become due to CONTRACTOR pursuant to this Agreement. Before making any such deduction,
R2R Intermodal Inc. shall give CONTRACTOR an itemized statement, setting forth the amount and
allocation of any such deductions.
C. LICENSE PLATES, CONTRACTOR shall purchase and pay for all license plates necessary for the
operation of the equipment leased herein, in CONTRACTOR’S name, and said license plates shall
remain the sole property of CONTRACTOR.
D. CHARGES, Neither CONTRACTOR nor any personnel furnished by CONTRACTOR shall charge any
purchases, of any nature. To R2R Intermodal Inc., should CONTRACTOR or its personnel, in violation
of this Paragraph, charge any purchases to R2R Intermodal Inc. R2R Intermodal Inc. shall have the
right to set off and deduct the amount of any such charges, together with any administrative expenses
incurred, from any monies due or which may become due to CONTRACTOR pursuant to this
Agreement and to avail itself of any other remedies described elsewhere in this Agreement. Before so
doing, shall give CONTRACTOR a written statement of all such charges and set-offs.
E. ADVANCES, In the event that R2R Intermodal Inc. shall be required to make any advances or
payments for and/or on behalf of CONTRATOR’S obligation for necessary operating expenses or
repairs on said Equipment, then R2R Intermodal Inc. shall have the right to withhold an equivalent sum,
plus any administrative expenses incurred by R2R Intermodal Inc., in making such advances, as a setoff,
from funds due CONTRACTOR as rental payment hereunder, or from any other sums which R2R
Intermodal Inc. may owe to CONTRACTOR, to secure the repayment of any such advances or
payments. R2R Intermodal Inc. will first give CONTRACTOR an itemized written statement for, or
explanation of, all deductions made. CONTRACTOR hereby authorizes irrevocably any agent of any
court of record to appear for CONTRACTOR in such court and confess judgment, without process, on
favor of R2R Intermodal Inc. for such amounts of any advance or payments which R2R Intermodal Inc.
has made on behalf of CONTRACTOR which remains unpaid, together with reasonable costs of
collection, including attorneys’ fees, and to waive and release all errors which may intervene in any
such judgment, hereby ratifying and confirming all that said attorney may do by virtue hereof.
Page 3 of 10

F. R2R Intermodal Inc. NOT LIABLE, R2R Intermodal Inc. shall not, in any way, be liable for fire, theft,
loss or damage to the Equipment leased hereunder, no matter how arising.
G. INSURANCE, it is recognized that the United States Department of Transportation and various other
regulatory bodies require the carrier under whose certificates or permits leased Equipment is being
operated to be responsible to the public with respect to such Equipment while some is being operated
under its authority. R2R Intermodal Inc. will file, or has on file, with the United States Department of
Transportation and any other regulatory body having jurisdiction over its operations, evidence of
insurance in such amounts as may be required by law or regulation of said agencies, and will
continuously maintain in effect insurance in such amount.
CONTRACTOR shall secure, at its sole expense, insurance in the minimum amount of $1,000,000
combined single limits covering bob-tail and dead-heading on the Equipment leased herein and shall
furnish R2R Intermodal Inc. with a certificate naming R2R Intermodal Inc as an additional insured
thereunder. In addition, CONTRACTOR will carry at its sole expense, its own insurance coverage on
the Equipment leased for collision, fire, theft and other occurrence or catastrophe, and R2R Intermodal
Inc. shall be named as an insured thereunder also.
R2R Intermodal Inc. shall furnish and may charge back to CONTRACTOR all costs of public liability,
property damage, cargo and comprehensive insurance on the Equipment which is the subject of this
Agreement, while it is operated in the service of R2R Intermodal Inc. The actual amount to be charged
to CONTRACTOR for said insurance coverages shall be as act forth in APPENDIX “B” of this
Agreement. Further R2R Intermodal Inc. shall furnish CONTRACTOR with copies of and the policy
numbers of all such insurance policies, as well as certificates of insurance therefore containing all of the
information required by 49 C.F.R. §376.12(j) (2). CONTRACTOR’S responsibility to indemnify R2R
Intermodal Inc. for claims or losses, as set forth in this Agreement, is limited to the extent that such
claims or losses, or any portion thereof, are not covered by such insurance policies.
8. Insurance/Benefits/Warranties
A. INSURANCE COVERAGES, CONTRACTOR will carry, at the own expense, the following insurance
coverages with the described minimum limits:
1) Commercial General Liability Coverage. Commercial general liability coverage with $1,000,000
per occurrence limits.
2) Commercial Automobile Coverage. Commercial automobile coverage with minimum limits of
$1,000,000 combined single limit and $1,000,000 uninsured/underinsured coverage.
CONTRACTOR must prove that its coverage is primary and acceptable to R2R Intermodal Inc. To
determine this, CONTRACTOR will provide R2R Intermodal Inc. with a duplicate copy of its
commercial auto policy. R2R Intermodal Inc will notify CONTRACTOR within thirty (30) days of
acceptance if coverage or certificate is not acceptable.
3) Workers’ Compensation Coverage or Occupational Accident Insurance. CONTRACTOR shall
maintain workers’ compensation coverage for CONTRACTOR, its agents, servants and employees.
B. CERTIFICATE OF INSURANCE. CONTRACTOR will furnish R2R Intermodal Inc an insurance
certificate for all required coverages shown above naming R2R Intermodal Inc. as an “Additional
Insured” on the general liability and commercial auto liability coverages. Contractor or its insurance
Page 4 of 10

carrier(s) shall give R2R Intermodal Inc not less than thirty (30) days prior notice of any cancellation of
any insurance policy or coverage(s) or such cancellation shall not be effective as to R2R Intermodal Inc.
C. NO BENEFITS. CONTRACTOR further understands and agrees that CONTRACTOR and
CONTRACTOR’S subcontractor, agents or employees are not entitled to any employee benefits
normally granted to R2R Intermodal Inc’s employees, and CONTRACTOR shall indemnify and hold
R2R Intermodal Inc. forever harmless from any and all liabilities (including expense and attorneys’
fees) and all costs, loss, expenses or damages are arising from employee compensation or benefits,
unemployment, Social Security or any other tax deduction or any employee benefits including, but not
limited to, group accident and health insurance or any workers’ compensation claims, injuries to or
omissions of CONTRACTOR or CONTRACTOR’S subcontractors, agents or employees for failure to
comply with the terms and obligations of this Agreement.
D. CONTRACTOR NOT COVERED. It is expressly understood and agreed that, because of
CONTRACTOR’S independent contractor status, R2R Intermodal Inc. is not obligated to carry any
insurance covering CONTRACTOR, including workers’ compensation insurance, and that
CONTRACTOR shall be responsible for the payment of premiums on any health, liability, or accident
insurance carried by CONTRACTOR for its protection, or the protection of its subcontractors, agents
and employees.
E. DRIVERS QUALIFIED. CONTRACTOR warrants that CONTRACTOR will furnish to operate all
Equipment leased pursuant to this Agreement only drivers or personnel who are qualified and
competent. CONTRACTOR agrees that all drivers and personnel furnished will be required to meet all
of the rules and regulations o the United States Department of Transportation, and any other regulatory
body having jurisdiction as to safety, hours of service, inspection and maintenance, the taking of
physical examinations, and furnishing a certificate therefore. All drivers and personnel will be required
to comply as to the qualifications, training program, drug and alcohol testing and safety rules of the
United States Department of Transportation, and any other body having jurisdiction. It is further agreed
that all drivers and personnel furnished by CONTRACTOR shall comply with all rules and regulations
prescribed by any regulatory body having jurisdiction over the operations to be conducted pursuant to
this Agreement. CONTRACTOR will ensure that all records pertaining to the foregoing will be
furnished to R2R Intermodal Inc. In order that R2R Intermodal Inc. can keep and maintain such
records in accordance with the rules and regulations of all regulatory bodies having jurisdiction over
these operations.
F. FINES AND PENALTIES. R2R Intemrodal Inc shall not be responsible for any fine, expenses or
costs incurred by CONTRACTOR or any drivers or personnel furnished by CONTRACTOR, by reason
of its or their violation of, or failure to adhere to, any federal or state law, local ordinance or regulation,
or rule or regulation of any federal, state or local regulatory body having jurisdiction; provided,
however, that R2R Intermodal Inc. agrees to pay all fines and penalties inadequacies in operating
authorities or license where it is mandatory that such be issued in R2R Intermodal Inc. R2R Intermodal
Inc. shall be responsible for fines for overweight or over-dimension trailers when trailers are pre-loaded
sealed or the load is containerized, or when the trailer or lading is otherwise outside of
CONTRACTOR’S control, except when such fine shall be the result of an act or mission of
CONTRACTOR or personnel furnished by CONTRACTOR.
G. CONTRACTOR’S PERSONNEL. As between R2R Intermodal Inc. and CONTRACTOR, except as
may be otherwise required by law or regulation, CONTRACTOR shall be solely responsible for the
direction and supervision of all personnel furnished by CONTRACTOR in connection with this
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Agreement, including, but not limited to, the selection, hiring, firing, supervising, directing, training,
setting wages, hours and working conditions, paying and adjusting grievances. As between
CONTRACTOR and R2R Intermodal Inc. only, CONTRACTOR shall be solely and exclusively
responsible for all aspects of the operation of the Equipment leased hereunder.
9. Compensation
A. The compensation and additional terms affecting payment of that compensation are stated in
APPENDIX “B,” attached to this Agreement and made a part hereof.
B. In order that CONTRACTOR may verify the accuracy of all payments made pursuant to this
Agreement, where payment is predicated upon a percentage of gross revenues, R2R Intermodal Inc.
shall present CONTRACTOR with copies of rated freight bills, or a computer-generated document
containing all of the same information, for all shipments transported in or with equipment leased
pursuant to this Agreement. CONTRACTOR shall have the right to examine copies of R2R Intermodal
Inc. tariffs or rate schedules at R2R Intermodal Inc. home office during reasonable business hours. In
those circumstances when CONTRACTOR is given a computer-generated document rather than a copy
of a freight bill, CONTRACTOR shall have the right to examine the source document(s) from which
such computer-generated information was compiled, under the same conditions. However, R2R
Intermodal Inc. shall have the right to block out or obliterate all references on such freight bills, source
document(s), tariffs and rate schedules as to the identity of customers, shippers and consignees.
10. CONTRACTOR’s General Duties
A. INSPECTION/WARRANTY. R2R Intermodal Inc. shall, prior to taking possession of the
Equipment, Inspect said equipment. CONTRACTOR warrants that the Equipment is complete with all
required accessories, appurtenances and appliances, and that the same is in good, safe and efficient
operating condition and shall be so maintained, at CONTRACTOR’S sole expense throughout the
duration of this Agreement. CONTRACTOR shall and will submit said Equipment for R2R Intermodal
Inc. Inspection at the time R2R Intermodal Inc. takes possession and periodically thereafter, as required
by R2R Intermodal Inc. CONTRACTOR shall furnish R2R Intermodal Inc. with all necessary
information and documents of title or registration so as to enable R2R Intermodal Inc. to correctly
identify and license the Equipment. CONTRACTOR shall furnish R2R Intermodal Inc copies of all
statements or invoices for repairs to said Equipment on a monthly basis, whether than by
CONTRACTOR or by a third party. R2R intermodal Inc. reserves the right to inspect the Equipment at
any time, and if R2R Intermodal Inc exercises this right and the Equipment shall be utilized in R2R
Intermodal Inc. service, as R2R Intermodal Inc. sees fit, CONTRACTOR shall not hinder or deter R2R
Intermodal Inc’s utilization in any manner whatsoever, Nothing in this Paragraph or Agreement shall
obligate R2R Intermodal Inc. utilize said Equipment with any specific frequency, for any specific
number or miles, trips or pounds of freight.
B. RECEIPTS FOR EQUIPMENT. When possession of said Equipment is taken by R2R Intermodal
Inc. under the terms of this Agreement, R2R Intermodal Inc. shall issue to CONTRACTOR, on the form
attached hereto as APPENDIX “C,” a receipt for said Equipment, stating the date and time at which
possession is taken. When possession is retaken by CONTRACTOR, CONTRACTOR shall give R2R
Intermodal Inc. a similar receipt on the form attached hereto as APPENDIX “C.” This Agreement shall
not be considered terminated, for the sole purpose of calculating the time limits for payment of trip
settlements due to CONTRACTOR hereunder, until CONTRACTOR has given R2R Intermodal Inc.
its receipt, as act forth herein above acknowledging return of the Equipment to CONTRACTOR. Upon
Page 6 of 10

termination of this Agreement, R2R Intermodal Inc. shall not be obligated to pay any accrued rentals
due to CONTRACTOR in connection with said Equipment, until after CONTRACTOR’S receipt for
the Equipment is received by
11. Subleasing/Trip Leasing/Etc.
A. R2R Intermodal Inc. may sublease the Equipment which is the subject of this Agreement whenever
permitted by applicable laws and regulations, and R2R Intermodal Inc. shall be considered to be the
owner of said Equipment for the purpose of any such subleasing if such is required by law or
regulation. Neither party may assign this Agreement. CONTRACTOR may not act as R2R Intermodal
agent for the trip of sublease of the subject Equipment, except upon such express terms and conditions
as R2R Intermodal Inc. may establish. In the event that CONTRACTOR trip-leases the subject
Equipment without first having obtained R2R Intermodal Inc. approval, then R2R Intermodal Inc shall
not be responsible to CONTRACTOR for the payment of any monies relating to said trip lease, unless
and until R2R Intermodal Inc. has actually received payment from the trip-lease carrier, nor shall R2R
Intermodal Inc. be responsible for any obligations to any trip-lessee undertaken by CONTRACTOR
Further, it is the responsibility of CONTRACTOR to submit all paper work relating to a trip-lease
shipment to R2R Intermodal Inc. and not to the trip-lease carrier. R2R Intermodal Inc shall then
immediately forward said paperwork to the trip-lease carrier.
B. Consistent with its independent contractor status, CONTRACTOR is free to, and may, lease or trip to
other carriers at such times as the Equipment that is not being utilized by R2R Intermodal Inc, If
CONTRACTOR enters into a sublease, CONTRACTOR agrees to assume all responsibility and hold
R2R Intermodal Inc harmless from any claim by CONTRACTOR, its subcontractors, agents or
employees during such sublease.
C. At those times when CONTRACTOR is not operating under R2R Intermodal Inc. operating authorities
or otherwise operating in R2R Intermodal Inc. service pursuant to this Agreement, or is hauling for
someone else, CONTRACTOR agrees to cover or remove any signs and/or other identification on the
Equipment containing R2R Intermodal Inc. name and or motor carrier identification numbers.
12. Indemnification by Contractor
As between R2R Intermodal Inc. and CONTRACTOR only, without any regard or effect upon the
obligation R2R Intermodal Inc. any third party, CONTRACTOR agrees to be responsible for, indemnify and
hold R2R Intermodal Inc. harmless from any and all claims of any nature, losses, personal injury, death, and/or
damage to cargo or other property, and/or claim for any such loss or occurrence which may arise from or in
connection with the operations performed or to be performed pursuant to this Agreement, however arising,
without regard to fault or negligence on the part of CONTRACTOR. This is to include, but is not limited to,
attorneys’ fees and any other expenses incurred in defending or processing any claim arising as a result of any of
the above or operation of the Equipment leased herein. R2R Intermodal Inc. may deduct any sums for which
CONTRACTOR is responsible hereunder from any monies that R2R Intermodal Inc. may owe to
CONTRACTOR as rentals or from any other sums which R2R Intermodal Inc. may owe to CONTRACTOR
after first giving CONTRACTOR on itemized statement therefore.
Page 7 of 10

13. Miscellaneous Provisions
A. LABOR DISPUTE. CONTRACTOR hereby agrees that should it become involved in a labor
dispute with its employees or with drivers or other personnel furnished to R2R Intermodal Inc. It
will immediately report such fact to R2R Intermodal Inc. If such labor dispute interferes or tends to
interfere with the operations of CONTRACTOR for R2R Intermodal Inc. pursuant to this
Agreement, then this Agreement shall be subject to immediate cancellation by R2R Intermodal Inc.
without penalty.
B. RENT/PURCHASE. CONTRACTOR is not required to purchase or rent any products, equipment
or service from R2R Intermodal Inc. as a condition of this Agreement.
C. LOADING/UNLOADING. Loading of freight onto the Equipment, which is the subject of this
Agreement, is the responsibility of CONTRACTOR and shall be done at CONTRACTOR’S
expense. Unloading of freight is the responsibility of CONTRACTOR and shall be done at
CONTRACTOR’S expense.
D. R2R Intermodal Inc’s TRAILER. In the event that a vehicle leased from CONTRACTOR
pursuant to this Agreement shall be utilized pulling trailer or chassis furnished by R2R Intermodal
Inc. and during the course of any such operation any such trailer should become damaged,
regardless of how such damage may occur, by or during said operations, then CONTRACTOR
shall pay to R2R Intermodal Inc. all such damages to said trailer and all other consequential
damages which R2R Intermodal Inc. may suffer flowing there from, after first giving
CONTRACTOR credit for any sums recovered by R2R Intermodal Inc. by way of insurance or
otherwise, with regard to said trailer.
E. COMPLETE AGREEMENT. This Agreement shall supersede, replace and take precedence over
any prior agreement of a similar character between the parties hereto. This Agreement shall
constitute the complete Agreement between the parties, and no agent or employee of either party
shall have the authority to alter or vary the terms hereof or to make any representations or
commitments not included herein. This Agreement shall not be assignable except with the express
written consent of both parties. This Agreement shall be interpreted and governed pursuant to the
laws of State IL and any action pertaining thereto shall be brought and maintained exclusively in
Courts in the State of IL.
F. COPIES. This Agreement shall be executed in at least three (3) copies, each of which shall be
considered an original, to the end that one executed copy, known as “R2R Intermodal Inc. Copy”
shall be retained by R2R Intermodal Inc. one executed copy known as “CONTRACTOR’S Copy”
shall be retained by CONTRACTOR; and one executed copy known as “Equipment Copy” shall be
carried in the Equipment during the term of this Agreement and returned to R2R Intermodal Inc. at
the conclusion of this Agreement. Additional copies may be signed where necessary, and, when
signed, such additional copies shall also be considered as originals and may be filed with
appropriate regulatory bodies.
14. Independent Contractor Status/Tax Treatment
Page 8 of 10

CONTRACTOR acknowledges and agrees that it has been engaged as an independent contractor and
not as an employee. It shall be, therefore, responsible for payment of all federal, state and local taxes arising out
of Its activities under this Agreement, and/or the activities of its subcontractors, agents and employees including
by way of Illustration, but not limitation, federal and state income tax, Social Security tax, unemployment
insurance taxes, where applicable, and business license fees, where required. CONTRACTOR understands and
agrees that R2R Intermodal Inc. is not obligated or responsible to deduct any taxes which may be imposed by
any governmental authority from the fees as paid to CONTRACTOR or CONTRATOR’S subcontractors, agents
or employees by R2R Intermodal Inc. under this Agreement, but that any such tax obligations are the sole
responsibility of CONTRACTOR. R2R Intermodal Inc. is not authorized to withhold state of federal income tax,
or Social security tax upon the sums paid CONTRATOR or CONTRACTOR’S subcontractors, agents and
employees.
15. Invalidity
In the event any provision of this Agreement shall be held to be invalid, it shall not affect the validity of
the remainder of this Agreement.
16. Notices
Any written notice required by the terms of this Agreement shall be given either by personal delivery,
by certified mall, premium overnight delivery service, telecopier or such other means as the parties shall in
writing agree upon.
17. Headings
The headings of this Agreement’s provisions are for convenience only and shall not control or affect the
meaning or construction or limit the scope or intent of any of this Agreement’s provisions. All headings shall be
subordinate to the meaning of the text of the Agreement.
NAME OF CONTRACTOR’S
Business:
__________________________________
By________________________________
Representative’s Signature
Its _________________________________
Representative’s Title
R2R INTERMODAL INC.
By __________________________________
Authorized Agent
(Attached Business Card of Contractor)
Please supply Federal Employer Identification
Number (FEIN)
Page 9 of 10

Please supply IDES Account Number, if
any _________________________________
Operating Authority (if any)
MC Number: _________________________
Page 10 of 10

R2R Intermodal Inc.
Cell Phone Policy
The rule prohibits interstate commercial motor vehicle (CMV) drivers from using hand-held cell
phones while driving. Under the new rule, CMV drivers will not be able to hold, dial, or reach for
a hand-held cell phone, including those with push-to-talk capability. Hands-free phone use is
allowed, as is the use of CB radios and two-way radios.
Specifically, the rule prohibits drivers from:
Using at least one hand to hold a mobile phone to conduct a voice communication;
Dialing or answering a mobile phone by pressing more than a single button, and
Reaching for a mobile phone in a manner that requires the driver to maneuver so that
he or she is no longer in a seated, belted, driving position.
Drivers will not be able to use hand-held phones while temporarily stopped due to traffic, a
traffic control device, or other momentary delays, but they will be able to use them after
moving the vehicle to the side of, or off, the highway and stopping in a safe location.
Disciplinary Program for Cell Phone Violation
1 st Violation: Written Warning / Retraining / 2 days Off
2 nd Violation: Review of Records / Begin Termination of Employment
Driver Signature: ___________________________________
Date_____________
Employer Signature:__________________________
Date

Unauthorized Passengers
To provide the company and employees with a clear understanding of the safety risks involved in
transporting “Unauthorized Passengers” in company equipment.
No employee shall transport or permit any person to be transported on/in any motor vehicle under the
authority of the company, except as defined by Federal Motor Carrier Safety Regulations, Part 392.
Unless specifically authorized in writing by the company whose authority the motor carrier is operated,
no employee shall transport or permit any person to be transported on/in any motor vehicle other than
a bus.
When such authorization is issued, it shall state the name of the person to be transported, the point
where the transportation is to begin and end and the date upon which such authority expires. No
written authorization, however, should be necessary for the transportation of:
• Employees or other persons assigned to the vehicle by the company;
• Any person transported when aid is being rendered in case of an accident or emergency.
Employees operating company equipment must understand and abide by the policy.
The company must inform all employees operating company equipment of the “Unauthorized
Passenger” policy.
Employees must read and sign the acceptance document acknowledging the “Unauthorized Passenger”
policy.
Employees violating the “Unauthorized Passenger” policy are subject to the progressive disciplinary
policy.
Driver’s signature: _____________________
Date: ______________

Pre-Employment Checklist
Training Video
As part of R2R’s employment screening process, driver must show adequate knowledge of rules,
regulations, and safety procedures. For training purposes R2R provides a video for drivers that
explains basic safety, driver qualifications, and how to fill out daily driving logs.
I have watched and understood “CMV Driver Basics for Entry Level Training”.
Driver Signature
Date
Test Drive
Driver is required to perform the following for an R2R representative:
- A full pre-trip inspection
- Hook onto chassis
- Back chassis up into designated area
- Demonstrate filling out a daily log and POD
Driver Signature
Date
R2R Signature
Date

MOTOR VEHICLE DRIVER’S
Certification of Violations/Annual Review of Driving Record
CERTIFICATION OF VIOLATIONS—COMPLETED BY DRIVER
Driver Name: (Please Print)
Date of Employment
Home Terminal(City and State) Driver’s License Number State Expiration Date
I certify that the following is a true and complete list of traffic violations (other than parking violations) for which
I have been convicted or forfeited bond or collateral during the past 12 months.
Date of conviction Offense Location Type of motor vehicle operated
If no violation are listed above, I certify that I have not been convicted or forfeited bond or collateral on account
of any violation required to be listed during the past 12 months.
Date of certification
Driver’s Signature
COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD
MOTOR CARRIER: Each motor carrier shall, at least once every 12 months, require each driver it employs to
prepare and fumish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations
involving only parking) of which the driver has been convicted or on account of which he/she has forfeited bond or
collateral during the preceding 12 months.
(FMCSR 391.27)
I have hereby reviewed the driving record of the above named driver in accordance with section 391.25 and find
that he/she (check one):
Meets minimum requirements for safe driving Is disqualified todrive a motor vehicle pursuant to Section 391.15
Does not adequately meet satisfactory safe driving performance
Reviewed by:
Signature
Date
Printed Name
Title
Motor Carrier Name Motor Carrier Address

LEASE AGREEMENT
Note: This Lease Agreement should be maintained in the Equipment during the term of the Agreement.
I. I, _________________________________________________________________________ (Carrier/Registrant)
Address: _______________________________________________________________________________, and
___________________________________________________________________________(Equipment Owner)
are parties to a written Lease Agreement (Agreement), whereby the Equipment Owner has leased to the Carrier
certain motor vehicle equipment listed below, owned and controlled by the Equipment Owner, whereby the
Equipment Owner is providing the Carrier as operator or operators of the Equipment for the purpose of loading,
transporting and unloading freight.
II.
The Original Agreement is on file at the Carrier’s General Office. A copy of this Lease Agreement and receipt for
the Equipment must be carried on the Equipment as required by 49 CFR §376. Carrier verifies that the Equipment
is being operated by the Carrier, pursuant to the terms of the Agreement.
III.
Equipment Owner/Equipment Information
Name:___________________________________ Phone #: _______________________________________
DBA: ____________________________________ Contact:________________________________________
Address: _________________________________
FEIN: __________________________________________
_________________________________
Year: _______ Make: ____________________ VIN: ________________________________ Unit #: __________
IV.
Duration of Lease Agreement and Termination
The Lease Agreement shall begin on the date below and shall remain in effect until terminated by either party, giving
notice to that effect. Notice may be given personally, by mail or by fax at the address or fax number shown in
the Lease Agreement.
MOTOR CARRIER/REGISTRANT
By: ____________________________________________
Date: __________________________________________
EQUIPMENT OWNER
By:____________________________________________
Date: __________________________________________
MC #:__________________________________________
USDOT #: ______________________________________
Printed by authority of the State of Illinois. November 2011 — 1 — VSD 683.2