Carrier Set Up

All required fields are marked with '*'.
Vendor Information
Carrier Information Remit Information
Date: 3/1/2015 Address*:
Carrier Name*: City*:
Address*: State*:
City*: Zip Code*:  
State*: Telephone*:  
Zip Code*:   Fax:  
Pertinent Information Contact Information for POD
 Operating Authority (MC #)*:  Name*:
US DOT #: Telephone*:  
Federal ID #*: Fax:  
SCAC Code (if applicable):
SVI # (if applicable):
General Liability Insurance: Important Note
Automobile Liability Insurance: Please fax the Certificate of Insurance to 814-461-7645
Workers Compensation Insurance:    
Motor Truck Cargo Insurance:    
Equipment Types Contact Information of Applicant
  (select any of the following that apply) Name*:
Qty:   Qty:  
Qty:   Qty:  
Qty:   Qty:  
Qty:   Qty:  
Please type the characters you see above in the box below.