Instructions: (Please fax or email the completed documents) dispatch@txcarriers.com Fax: 1-855-631-4174 o Fill o Copy o Copy o initial o Insurance out Carrier profile of Common Carrier Authority Company name must match the name on the certificate of insurance. of Carrier s Hazmat Transportation Authority (if Applicable) every page and sign last page of the broker/carrier Contract Certificate (See Request for proper insurance) $250,000 Cargo Liability (Required) $1,000,000 Auto Liability (Required) $1,000,000 General Liability (Required) $100,000 Loss or damage to Non Owned Liability (Required) Must show TransX Ltd as ADDITIONAL INSURED o Completed TransX LTD 2595 Inkster Blvd. Winnipeg, Manitoba R3C 2E6, Canada W-9 or W-8 form (US Carriers only) Initials 1 P a g e
NEW CARRIER SIGN UP REQUEST FORM Company Name: Physical Address: Carrier Contact Information Legal Name DBA / Operating Name Street Address Unit # Mailing Address: City State/Province ZIP /Postal Code Country Street Address Unit # City State/Province ZIP /Postal Code Country Work Phone: Fax: Toll Free Number: Emergency Phone Day: Dispatch Phone: Emergency Phone Night: Contact Name: Last Name First Name Email: Company url: Email: Authority Common Contract Exempt C-TPAT Smart Way Authority Numbers: DOT# ICC/MC# SCAC Code SVI# (C-TPAT) D&B# EIN# Initials 2 P a g e
Type of Carrier Asset Based Company Type Freight Forwarder Carrier Profile 3PL Individual Corporation Partnership LLC Service Type LTL TL Intermodal Ocean Air Local Regional National International Technology Satellite Tracking Fleet Size Owned / Leased Equipment XML EDI Capability Brokers Teams Online Tracking Reefers Dry Flatbeds Intermodal Reefer Trailers Length Straight 45 48 53 Dry Trailers Length Straight (24-32 ) 45 48 53 Flat Bed Trailers Length Flatbed Lowboy Drop Deck Double Decker Intermodal Chassis Length 20 40 Insurance Cargo: 20-40 Combo 20-53 Extendable Insurance Carrier Insurance Agent Policy Number Insurance Phone Insurance Contact Certificate Requested Insurance Amount Insurance Deductible Expiration Date General Liability: Insurance Carrier Insurance Agent Policy Number Insurance Phone Insurance Contact Certificate Requested Insurance Amount Insurance Deductible Expiration Date Initials 3 P a g e
Reference: Terminal Locations: Initials 4 P a g e
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