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Date
*
MM slash DD slash YYYY
Company
*
MC Number
*
DOT Number
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
*
Extension
Do You Use a Factor?
*
Yes
No
Notice of Assisgnment
*
Please upload your Factor's Notice of Assignment Document
Max. file size: 50 MB.
Payment terms:
28 Days
– No fees – Check is mailed or payment direct deposited within 28 days of 3SIX5 receiving complete and legible paperwork. Please email invoice, rate confirmation and all delivery documentation to
[email protected]
. If original documents are required, please mail them.
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Payment Terms Choice
*
I would like to use the following payment plan (outlined above):
28 Day - No Fees
7 Day Quick Pay - 5% Fees
Primary Contact Name
*
First
Last
Primary Contact Phone
*
Extension
After Hours Phone
*
After Hours Extension
Primary Contact Email
*
Fax
Do You Have A Single Carrier Packet File?
*
File must contain: W-9, Certificate of Liability, and Carrier Authority
Yes
No, My paperwork is in separate files.
W-9
*
Max. file size: 50 MB.
Certificate of Liability Insurance
*
Max. file size: 50 MB.
Carrier Authority
*
Max. file size: 50 MB.
Carrier Packet
*
Max. file size: 50 MB.
Your Insurance Agent's Name
*
Your Insurance Agent's Email
*
Your Insurance Agent's Phone Number
Your Insurance Agent's Fax Number
Your Company Name (as on the certificate)
*
Enter your trucking company's info here, as it reads on your insurance certificate.
Address of Your Company (as on the Certificate)
*
Enter your business address as it reads on the Certificate of Insurance
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