New Carrier Packet Checklist

New Carrier Packet Checklist
Below is a list of the documents required by Exxact Express, Inc. to be set up as a carrier:
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“New Carrier Information” Page
W-9
Liability, Cargo and Worker's Comp Certificates of Insurance
q Exxact Express, Inc as certificate holder
q Notice of cancellation or change
Authority Documentation containing MC Number
Signed Exxact Express, Inc. Carrier - Broker Agreement
Factoring company information for payment (if applicable)
Telephone 800-443-3798 • 863-682-4101 • Fax 863-688-7660
P. O. Box 95545 • Lakeland, FL 33804-5545
***THIS FORM MUST BE COMPLETED***
DATE OF AGREEMENT:
New Carrier Information
800-443-3798 FAX: 863-688-7660
Carrier
Name:
Phone Number:
Address:
Phone 800 Number:
City:
State:
Fax Number:
Zip:
E-mail:
SCAC Code:
Dispatcher:
Equipment
Hazmat Endorsed:
YES
Tractors:
Dry Vans: 48'
53'
Reefers:
53'
48'
Areas Serviced
Preferred States:
North East
Central
South East
North West
Mid West
South West
NOTES
Telephone 800-443-3798 • 863-682-4101 • Fax 863-688-7660
P. O. Box 95545 • Lakeland, FL 33804-5545
NO
EXXACT EXPRESS, INC.
CARRIER - BROKER AGREEMENT
This agreement is entered into between EXXACT EXPRESS, INC., a licensed I.C.C. Property Broker, MC 200412,
_____________________________________, whose
address is ________________________________________________, herein
herein after referred to as BROKER
after referred to as CARRIER.
WHEREAS, the BROKER is a licensed Property Broker and engaged in the business of negotiating and conducting the
transportation of regulated commodities in interstate commerce over public highways; and
WHEREAS, the CARRIER is a Motor Carrier operating in interstate commerce, Pursuant to operating authority issued
to it by the Interstate Commerce Commission;
NOW THEREFORE, in consideration of the mutual covenants and promises hereinafter set forth, the parties agree as
follows:
1. The term of this Agreement shall be perpetual, provided however, that either Party may terminate the same
upon 30 days written notice. If, however, the CARRIER institutes termination, CARRIER agrees it will not directly or
indirectly solicit any BROKER accounts which were tendered to the CARRIER by the BROKER beyond the date of
cancellation. As liquidated damages upon violation of this clause, CARRIER agrees to pay back a 15% commission on
all traffic handled for customers introduced to CARRIER by BROKER for a period of 18 months following the
termination of this Agreement.
2. The CARRIER agrees to transport goods for mutually agreed rates, negotiated on a per load basis by both
parties.
3. The CARRIER agrees to transport such goods on its equipment and will not broker, interline, co-broker, assign
or trip lease freight under this agreement. In no event will BROKER or its customer(s) be held liable for freight payment
to sub-contracted carriers due to violation of this clause.
4. The CARRIER shall be liable for all loss, damage, or liability occasioned by transportation of property arranged
by the BROKER while being transported by the CARRIER.
CARRIER warrants to BROKER that it meets the following criteria: (a) CARRIER shall maintain all risk cargo insurance
in the amount of not less than $100,000 per shipment; (b) CARRIER shall maintain public liability insurance in the
amount of not less than $1,000,000 as required by federal regulation; (c) CARRIER shall maintain worker's
compensation as required by state law; (d) CARRIER shall be in compliance with all applicable laws.
BROKER shall be named as a "Certificate Holder" on the policies. CARRIER will not cancel or change coverage of the
insurance without giving BROKER written notice. CARRIER will be liable to BROKER for any and all damages resulting
from CARRIER'S failure to maintain required insurance.
5. The CARRIER shall uphold the good reputation of the BROKER and shall not misrepresent the services and
abilities of the BROKER.
6. The CARRIER shall invoice BROKER for freight charges due. CARRIER shall submit freight charges, along
with all original paperwork, to:
EXXACT EXPRESS, INC., P.O. Box 95545, Lakeland, FL 33804-5545
Under no circumstances will CARRIER invoice the customer/shipper/consignee, or solicit payment from them in any
form.
7. The CARRIER driver is required to call BROKER on a daily basis while under a load and must call to confirm
pickup and delivery. Failure to do so will result in a $50 fine.
8. Advance CARRIER payment is subject to a fee equal to the greater of 10% of the advance amount or $25.
BROKER will deduct fee from invoice payment.
9. The BROKER shall pay accessorial charges based on the following schedule if notified within 1 hour of
occurrence. Failure to do so will result in non-payment of accessorial charges.
Detention:
$ 25 / hour, 2 hours free
Unloading:
Match original lumper receipt as provided
Layover:
$ 100 / day, $ 100 max
Truck Ordered - Not Used: $ 100 / occurrence : Applicable only if notified < 24 hrs. before pickup
EXXACT EXPRESS, INC.
CARRIER:
BY:
BY:
Authorized Representative
Authorized Representative
Telephone 800-443-3798 • 863-682-4101 • Fax 863-688-7660
P. O. Box 95545 • Lakeland, FL 33804-5545
Exxact Express, Inc., is a 48 state contract carrier and licensed broker, incorporated in Lakeland, Florida.
MC NUMBER:
FEI NUMBER:
DUNS NUMBER:
200412
59-2898424
17-447-6267
CARRIER REFERENCES
McGriff Transportation, Inc.
P.O. Box 1148
Cullman, AL 35056
Attn: Jake Ext. 501
Telephone #: 800-950-9034
Fax #:
256-737-1835
Rosedale Transport, Inc.
P.O Box 3427
Dalton, GA 30719
Telephone #: 706-226-1003
Fax #:
706-279-1697
Baylor Trucking, Inc.
5114 N. State Road 101
Milan, IN 47031
Telephone #: 800-457-9752
Fax #:
812-623-2026
BANK REFERENCE
Mercantile Bank, N.A.
13577 Feather Sound Dr.
Clearwater, FL 33762
Attn: Patrick McManus
Telephone #: 727-561-4109
Fax #:
727-561-4130
INSURANCE CONTACTS
LIABILITY INSURANCE:
Reynolds & Reynolds of FL
800-773-5560
CARGO INSURANCE:
U.S. Insurance Group of FL
800-808-6865
WORKERS COMPENSATION:
Liberty Mutual Insurance Co.
800-282-6218
Telephone 800-443-3798 • 863-682-4101 • Fax 863-688-7660
P. O. Box 95545 • Lakeland, FL 33804-5545
SERVICE DATE
December 1, 1987
PM-25
(Rev. 10/84)
INTERSTATE COMMERCE COMMISSION
LICENSE
No. MC 200412
EXXACT EXPRESS
LAKELAND, FL
This License is evidence of the applicant’s authority to engage in operations as a broker.
This authority will be effective as long as the broker maintains compliance with the requirements
pertaining to insurance coverage for the protection of the public (49 CFR 1043) and the designation of agents
upon whom process may be served (49 CFR 1044). Applicant shall render reasonably continuous and
adequate service under this authority. Failure to meet these conditions will constitute sufficient grounds for
the suspension, change or revocation of this authority.
This authority is subject to any terms, conditions, and limitations as are now, or will be, attached to
this privilege.
The service to be performed is described on the reverse side of this document.
By the Commission.
(SEAL)
NORETA R. McGEE,
Secretary
NOTE: If there are any discrepancies regarding this document, please notify the Commission within 30 days.
OP ID: JW
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
11/16/11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
863-294-4241
863-294-4243
PRODUCER
GIS/Green Insurance Services
1500 6th Street NW
Winter Haven, FL 33881
CONTACT
NAME:
PHONE
(A/C, No, Ext):
E-MAIL
ADDRESS:
PRODUCER
CUSTOMER ID #: EXXAC-1
FAX
(A/C, No):
INSURER(S) AFFORDING COVERAGE
INSURED
Exxact Express, Inc.
Post Office Box 95545
Lakeland, FL 33804
INSURER A : Auto
NAIC #
Owners Insurance Co
18988
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL SUBR
INSR WVD
POLICY NUMBER
POLICY EFF
POLICY EXP
(MM/DD/YYYY) (MM/DD/YYYY)
GENERAL LIABILITY
LIMITS
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PROPOLICY
LOC
JECT
PRODUCTS - COMP/OP AGG
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE
OCCUR
$
$
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE
(Per accident)
HIRED AUTOS
$
$
NON-OWNED AUTOS
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
EXCESS LIAB
CLAIMS-MADE
AGGREGATE
$
$
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
A Broker Surety Bond
$
WC STATUTORY LIMITS
OTHER
E.L. EACH ACCIDENT
N/A
$
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT
66255337
09/15/11
09/15/12
Bond
$
10,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER
CANCELLATION
INSURED
Insured
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2009/09)
© 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD