“New Carrier Information” Page W-9 Liability, Cargo and Worker's Comp Certificates of Insurance Exxact Express, Inc as certificate holder Notice of cancellation or change Authority Documentation containing MC Number Signed Exxact Express, Inc. Carrier - Broker Agreement Factoring company information for payment (if applicable) q Telephone 800-443-3798 • 863-682-4101 • Fax 863-688-7660 New Carrier Packet Checklist Below is a list of the documents required by Exxact Express, Inc. to be set up as a carrier: q P. O. Box 95545 • Lakeland, FL 33804-5545 q q q q q q
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New Carrier Packet Checklist - Exxact Express Info Packet.pdf · New Carrier Packet Checklist Below is a list of the documents required by Exxact Express, Inc. to be set up as a carrier:
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“New Carrier Information” Page
W-9
Liability, Cargo and Worker's Comp Certificates of Insurance
Exxact Express, Inc as certificate holder
Notice of cancellation or change
Authority Documentation containing MC Number
Signed Exxact Express, Inc. Carrier - Broker Agreement
Factoring company information for payment (if applicable)q
If there are any discrepancies regarding this document, please notify the Commission within 30 days.
By the Commission.
This License is evidence of the applicant’s authority to engage in operations as a broker.
LAKELAND, FL
The service to be performed is described on the reverse side of this document.
EXXACT EXPRESS
This authority is subject to any terms, conditions, and limitations as are now, or will be, attached to
this privilege.
December 1, 1987
INTERSTATE COMMERCE COMMISSION
LICENSE
No. MC 200412
This authority will be effective as long as the broker maintains compliance with the requirements
pertaining to insurance coverage for the protection of the public (49 CFR 1043) and the designation of agents
upon whom process may be served (49 CFR 1044). Applicant shall render reasonably continuous and
adequate service under this authority. Failure to meet these conditions will constitute sufficient grounds for
the suspension, change or revocation of this authority.
NOTE:
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCETHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement(s).
CONTACTPRODUCER NAME:FAXPHONE(A/C, No):(A/C, No, Ext):
E-MAILADDRESS:PRODUCERCUSTOMER ID #:
INSURER(S) AFFORDING COVERAGE NAIC #INSURED INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
UMBRELLA LIAB EACH OCCURRENCE $OCCUREXCESS LIAB CLAIMS-MADE AGGREGATE $
$DEDUCTIBLE
$RETENTION $WC STATU- OTH-WORKERS COMPENSATION
TORY LIMITS ERAND EMPLOYERS' LIABILITY Y / NANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
N / AOFFICER/MEMBER EXCLUDED?(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $If yes, describe under
E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.