Z Brothers Express

(312) 919 5756

BECOME A CARRIER

Company Info:

Step 1 / 4

Company Name

Phone Number

Fax Number

Doing Bussiness As Name

E-Mail Address

Confirm Email Address

Street Address

City

State

Zip

Mailing Address (If different from above)

BUSINESS TYPE Corporation Partnership Proprietor LLC

If A Corporation, State of Incorporation

Social Security Number (if not a corporation)

If A Partnership Identify Partners

Federal Employer Identification Number (FEIN)

DOT Number

Do You Have Federal Motor Carrier Authority? Yes No

If Yes, Identify Motor Carrier Number (MC)

Contact Person:

Step 2 / 4

Name of Owner / Officer

Phone Number

E-Mail Address

Street Address

City

State

Zip

Truck / Insurance Information

Step 3 / 4

Do you own / lease trucks currently? Yes No

How many can you dedicate to Z Brothers Express Inc:

16' (cube) truck:

24'/26'(box) truck:

53'tractor trailer:

INSURANCE REQUIREMENTS:

Do you have current commercial liability coverage? Yes No

Do you have current cargo coverage? Yes No

Name of insurance agent:

Telephone Number:

Upload Sertificate Insurance (PDF):

See sample of correct sertificate insurance: Certificate of insurance sample/template

Account Info

Step 4 / 4

Name on the account

Account Type

Routing Number:

Confirm Routing Number:

Accounting Number:

Confirm Accounting Number: