Unique Giant Logistics

Attention Carriers please fill out your respective form below. We aim to respond to all inquiries within 24-48 hours! We look forward to working with you!

Dispatch Service Agreement

Instructions : Please complete this form giving us all the information that pertains to you and your company. The better informed we are, the better we will be able to assist you. This form should be updated at any time by notifying us. This information is for our use only and will not be released to any third party without your express written permission.

Company Name

DBA

Physical Address

Physical City

Physical State

Physical Zip

Mailing Address

Mailing City

Mailing State

Mailing Zip

Main Person Contact

Office Phone

Fax

Cell Phone

Emergency Contact Person

Emergency Phone

MC #

Years Active

DOT #

SCAC

# and type of Trailers

53’ VAN 53’ REEFERS 48’/53’ FLATBED POWER ONLY Box Truck HOTSHOT TANKER OTHER (write in notes)

Truck numbers

Trailer numbers

Trailer Accessories for your specific equipment types (Dry Van, Reefer, and Flatbed):

Notes (Others types, additional info)

PLEASE LIST THE BROKERS THAT YOU ARE ALREADY SET UP OR APPROVED WITH BELOW

CENTS ($) PER MILE

MAX # OF PICK UPS:

MAX # OF DELIVERIES

DRIVER TOUCH (Y/N)

Mountains?

TOLLS?

Weight Limit

HOME TIME

ENDORSEMENTS

TYPE OF ENDORSEMENTS

CLEARANCE TYPE: (TWIC, DBID, RAPID GATE, STA)

Areas (ZONES) of the USA you like to travel

Northeast (CT, DE, MA, ME, NH, NJ, NY, PA, RI, VT) Midwest (IA, IL, IN, KS, KY, MI, MN, MO, MT, NE, ND, OH, SD, WI) Southeast (AL, FL, GA, MD, MS, NC, SC, TN, VA, WV) Southwest (AR, AZ, LA, NM, OK, TX) West (AK, AZ, CA, CO, ID, NM, NV, OR, UT, WA, WY)

Additional Comments

Insurance Company

Policy #

Agent Name

Agent Contact #

Auto Liability Coverage (min 100,000)

Cargo Coverage (min 100,000)

General Liability (if applicable)

MC Authority Letter (Certificate)

Certificate of Insurance (C.O.I.)

If Applicable: Factoring company’s credit application (so that they can run the credit on the brokers and send a Notice of Assignment (N.O.A.) if the credit is favorable).