Avillion LLC

Carrier set up

Carrier Profile

Carrier name: (Required)

Address Line 1: (Required)

Address Line 2: (Optional)

City: (Required)

State: (Required)

ZIP / Postal code: (Required)

Phone number: (Required)

Phone Ext: (Optional)

Checks Payable To: (Optional)

Remit To Address Line 1: (Optional)

Remit To Address Line 2: (Optional)

Remit To City: (Optional)

Remit To State: (Optional)

Remit To ZIP/Postal Code: (Optional)

Remit To Phone Number: (Optional)

Remit To Phone Ext: (Optional)

Factoring Co Name (Optional)

Factoring Co Address Line 1 (Optional)

Factoring Co Address Line 2 (Optional)

Factoring Co City (Optional)

Factoring Co State (Optional)

Factoring Co ZIP/Postal Code (Optional)

Factoring Co Phone Number (Optional)

Factoring Co Phone Ext (Optional)

MC/FF/MX Number: (Required)

USDOT Number: (Required)

Tax ID: (Required)

1099 Vendor

Primary Contact Name: (Required)

Primary Contact Telephone: (Required)

Primary Contact Ext (Optional)

Primary Contact Email: (Required)

Secondary Contact Name (Optional)

Secondary Contact Telephone (Optional)

Secondary Contact Ext (Optional)

Secondary Contact Email (Optional)

CARGO

Underwriter Company Name (Required)

Agent Name (Required)

Street Address (Required)

City (Required)

ST (Required)

ZIP (Required)

Phone (Required)

Email (Required)

Policy Number (Required)

Effective Date (Required)

Expiration Date (Required)

Coverage Amount (Required)

AUTO

Underwriter Company Name (Required)

Agent Name (Required)

Street Address (Required)

City (Required)

ST (Required)

ZIP (Required)

Phone (Required)

Email (Required)

Policy Number (Required)

Effective Date (Required)

Expiration Date (Required)

Coverage Amount (Required)

GENERAL

Underwriter Company Name (Optional)

Agent Name (Optional)

Street Address (Optional)

City (Optional)

ST (Optional)

ZIP (Optional)

Phone (Optional)

Email (Optional)

Policy Number (Optional)

Effective Date (Optional)

Expiration Date (Optional)

Coverage Amount (Optional)

Hired and Non-Owned Vehicle

Underwriter Company Name (Optional)

Agent Name (Optional)

Street Address (Optional)

City (Optional)

ST (Optional)

ZIP (Optional)

Phone (Optional)

Email (Optional)

Policy Number (Optional)

Effective Date (Optional)

Expiration Date (Optional)

Coverage Amount (Optional)

TruckType 1 (Optional)

Size (Optional)

Number Of Truck (Optional)

Specs (Optional)

TruckType 2 (Optional)

Size (Optional)

Number Of Truck (Optional)

Specs (Optional)

TruckType 3 (Optional)

Size (Optional)

Number Of Truck (Optional)

Specs (Optional)

TruckType 4 (Optional)

Size (Optional)

Number Of Truck (Optional)

Specs (Optional)

TruckType 5 (Optional)

Size (Optional)

Number Of Truck (Optional)

Specs (Optional)

Smart Way

CARB

FAST

TWIC

TSA

CTPAT

Woman Owned Business

Diversity Certification Agency (Optional)

HazMat

HazMat CertExpiration Date (Optional)

DOT HM-232

Carrier profile (Optional)

MC Authority (Required)

NOA - Notice of assignment (Required)

W9 Tax Purposes (Required)

COI - Certificate of Insurance (Required)

SCAC Code (Optional)

Other (Optional)