Enroll in Clearinghouse Form

Please complete the following form to request that Work Well enroll your Company in the FMCSA Portal/Clearinghouse. To begin, the Company's credit card on file will be charged an $80.00 non-refundable fee.
Company Name as identified on the MCS-150 form:*
Company Owner's Name: *
Company's Address:*
Street, City, State, Zip Code
Phone Number for Company that can receive text messages*

Area CodePhone Number
Company's e-mail address: *
Company's DOT number:*
Name and phone number of person/company who helped you file for your DOT number:*
Company's EIN Number:*
PIN number that the FMCSA provided when your Company completed its MCS-150 form (note - you can reset this after Work Well sets up your account(s)).*
PIN Number
MUST COMPLETE ALL FOUR STEPS

STEP 1 - FMCSA PORTAL ACCOUNT
The FMCSA Portal provides single sign-on access to FMCSA systems via a single password and user ID. Motor carriers use the FMCSA Portal to access crash, inspection, reviews, and census information contained on them in various FMCSA IT systems through a single interface.

If the Company has a DOT number, they should have signed up for an FMCSA Portal account, and that Portal account must be linked to the Clearinghouse.
The FMCSA requires motor carriers to link their FMCSA Portal Account with the FMCSA Clearinghouse. So that we may help your company be compliant with the FMCSA requirements please let us know the following:*

My company has an FMCSA Portal and wants Work Well to allow it to link to the Clearinghouse. (Please continue to questions below.)My company does not have an FMCSA Portal, but would like Work Well to create an FMCSA portal for my company and allow it to link to the Clearinghouse. (Please continue to questions below.)My company does not have an FMCSA Portal, and I understand the FMCSA requirements, yet I do not want Work Well to create an FMCSA Portal Account for my company. [Note - Work Well may not be able to completely enroll in the Clearinghouse without an FMCSA Portal Account.]
To link the FMCSA Portal Account to the Clearinghouse, Work Well must log into your company's FMCSA Portal Account and edit it to be able to link it to the Clearinghouse.

If your company knows its FMCSA Portal User Name and Password (+$10.00); if your company has an FMCSA Portal Account, but cannot remember the user name and/or password and Work Well has to work with the Company and/or the FMCSA to reset it (+$35.00); and if your company has no FMCSA Portal Account, and Work Well creates an account for your Company (+$30.00).
If the Company has an FMCSA Portal account and the Company wants it linked to the Clearinghouse, please provide the FMCSA portal user name. If no portal, please enter none.*
FMCSA Portal User Name
If the Company has an FMCSA Portal account, and the Company wants it linked to the Clearinghouse, please provide the FMCSA portal password (note - you can reset this after Work Well links the Company's account). If no portal, please enter none.*
FMCSA Portal User Password
If the Company does not have an FMCSA portal, but the Company wants to create a portal account, Work Well also needs the PIN number that the FMCSA provided the Company when you completed the Company's MCS-150 form (note - you can reset this after Work Well creates your account). (Also note - this will require you to provide us with the Company's DOT PIN number. If you don't know it, and we must work with the Company to reset it + $15.00).
PIN number

STEP 2 - ENROLL IN THE FMCSA CLEARINGHOUSE
The Clearinghouse provides the FMCSA and employers the necessary tools to identify drivers who are prohibited from operating a CMV based on DOT drug and alcohol program violations and ensures that such drivers receive the required evaluation and treatment before operating a CMV on public roads.

All companies and Owner-operators must join the FMCSA Clearinghouse. It has been mandatory since January 2020.
My Company wants Work Well to enroll it into the Clearinghouse and link Work Well as the Company's Consortium/Third Party Administrator (+ $25.00).*

YesNo
Does your Company have a login.gov account?

Yes (+$0.00)(Note - if the Company's username and/or password to login.gov is incorrect, and Work Well has to work with the Company to attempt to reset either the user name and/or the password +$35.00).No (+$25.00).
If your Company has a login.gov account, please provide the user name below.*
login.gov User Name
If your Company has a login.gov account, please provide the password below (note - you can reset this after Work Well links the Company's account).*
login.gov Password
NOTE - if your Company attempts to set up the Clearinghouse on its own, and it is set up incorrectly, Work Well must delete it (+$15.00).

STEP 3 - QUERIES IN THE FMCSA CLEARINGHOUSE
It is mandated that companies, as part of all pre-employment driver investigation as of January 2020, must conduct a "query" in the FMCSA Clearinghouse to determine wether the driver the Comapny seeks to hire is prohibited from driving a CDL. Also, at least annually for every CDL driver employed by the company, a query must be run.

A query is an electronic check in the Clearinghouse, conducted by an employer or their Consortium/Third Party Administrator, to determine if current or proscpective employees are prohibited from performing safety-sensitive functions, such as operating a CMV, due to unresolved drug and alcohol program violations.

There are two types of queries, limited queries (which satisfy the annual query requirement) and full queries (which include all pre-employment queries). All queries require driver consent.

The FMCSA cost for pre-purchasing one limited query is $1.25. The FMCSA also has query plans, if your Company anticipates conducting more than 100 queries in one year.

Work Well can use one of your ompany's pre-purched queries to conduct a query for the company. Work Well charges $2.00 each to run the query, using a pre-purchased query from your Company. We will then provide your Company a printed report, which is also stored in your Company's FMCSA Clearinghouse portal.
Does your Company want Work Well to help it pre-purchase queries, as described above, from the FMCSA Clearinghouse?*

Yes. (+$10.00 to place your Company's credit card information in the Clearinghouse and pre-purchase queries for your Company. If so, please complete the credit card authorization that Work Well will send the Company.)No, not at this time. I understand that Work Well will be unable to conduct a query for the Company if the Company has no pre-purchased queries.

LAST STEP - BILLING AND AUTHORIZATION
Name of individual authorizing above enrollment(s) on behalf of Company:*
The above-named individual, on behalf of the Company, authorizes Work Well to perform the enrollment(s) as indicated in this form. This may include, but not limited to creating accounts in the Company's name with the FMCSA Portal and FMCSA Clearinghouse.

The individual undertands that Work Well will enroll the Company as requested in this form, and it is the Company's duty - after Work Well has enrolled the Company - to review what Work Well has created and make all necessary corrections. After the enrollment(s), Work Well will provide the user name and password needed to access the website(s). The Company is also advised to change the password(s) on the account(s).

The individual and Company agree to comply with the FMCSA regulations related by the FMCSA portal and the FMCSA Clearinghouse.

The individual understands and authorizes that Work Well will charge the Company credit card on file an initial $75.00 non-refundable fee before Work Well performs any work. After the initial fee, Work Well will then charge for the remainder of the service(s) performed, in accordance witrh the charges set forth in this form. A detailed receipt will be provided.

If for some reason, Work Well is unable to complete the company's enrollment(s), Work Well will notify the company.
Company's Authorized Person's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Please complete the following form to request that Work Well enroll your Company in the FMCSA Portal/Clearinghouse. To begin, the Company's credit card on file will be charged an $80.00 non-refundable fee.

MUST COMPLETE ALL FOUR STEPS