Carrier Package (Coastline Connect)

Carrier Package
Thank you for your interest in being a carrier with Coastline Connect!

Page 1: Contact Information

Page 2: Carrier Agreement + Motor Carrier of Property Certificate of Compliance

Page 3: Form W-9

Page 4: Direct Deposit Form (including a voided check)

Page 4: Document Uploads*

*Please be prepared to upload a copy of the following:
1. Certificate of Insurance - General Liability $1,000,000
2. Certificate of Insurance - Automobile Liability $1,000,000
3. Certificate of Insurance - Cargo $100,000
4. Certificate of Insurance - Workman’s Compensation $1,000,000 per occurrence (if applicable)
5. Listing of equipment (tractors and trailers)
6. DMV Registration for all listed trucks or trailers
7. Air Resources Board Certificates for registered equipment
8. Listing of authorized drivers
9. Valid CA Commercial Driver's License for all authorized drivers
10. Medical Examiner’s Certificate for all authorized drivers
For any questions or concerns, please reach out to Christina Ochoa at coastlineconnectinc@gmail.com or (805) 509-0792.
Carrier Information
Carrier Company Name*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOT#*
CA#*
MC#
Authorized Company Officer
Name*

First NameLast Name
Title*
Phone Number*
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dispatching
Check this box if same as Authorized Company Officer
Name*

First NameLast Name
Title*
Phone Number*
Email*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing
Check this box if same as Authorized Company Officer
Name*

First NameLast Name
Title*
Phone Number*
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Incident / Accident Claims
Check this box if same as Authorized Company Officer
Name*

First NameLast Name
Title*
Phone Number*
Email*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts
Primary*

First NameLast Name
Relationship*
Phone Number*
Email
Secondary

First NameLast Name
Relationship
Phone Number
Email

Broker - Carrier Agreement
Please review the full agreement before signing. You can view and download the Broker-Carrier Agreement here: https://drive.google.com/file/d/10ug-T3dW2jxd6T00lWT_zYR62-GDu89_/view?usp=drive_link
This Transportation Agreement (the "Agreement"), is entered into this * day of *, 20 by and between Coastline Connect Inc. (hereinafter referred to as "BROKER") and Carrier Company Name* (hereinafter referred to as "CARRIER")
Authorized Signature*

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Authorized Signer's Information*

First NameLast Name
Title*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Motor Carrier Certification of Compliance

CHP 809 (Rev. 4-16) OPI 062
I, the undersigned, certify thatContracted Carrier's Name* holds a Motor Carrier of Property (MCP) Permit, Number CA#*, which is valid through Date*, and the above named carrier is knowledgeable of and in compliance with all applicable statutes and regulations including but not limited to (check al that apply):
Basic Inspection of Terminals ProgramControlled Substances and Alcohol Testing ProgramMCP
Name*

First NameLast Name
Title*
Signature*

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Date*

MonthDayYear
Date
Services Provided For (Contracting Carrier): Coastline Connect

Contracting CA Number: 6132395

One copy of this certificate shall be provided to the person for whom services are provided (the contracting motor carrier); one copy shall be retained by the motor carrier of property (the contracted motor carrier). Copies shall be retained by both parties for the duration of the contract or period of service plus two years, and shall be presented for inspection upon the request of an authorized employee of the California Highway Patrol or the Department of Motor Vehicles.

W-9

Request for Taxpayer Identification Number and CertificationGo to www.irs.gov/FormW9 for instructions and the latest information.
Please fill out the W-9 form fields below. To view the federal W-9 form and its instructions, scroll to the bottom of the page or click here.
1. Name of entity/individual. An entry is required. *
(For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.)
2. Business name/disregarded entity name, if different from above.
3a. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check ONLY ONE of the following seven boxes.*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLLC*Other (see instructions)
*If you checked the "LLC" box above, enter the tax classification (C = C corporation, S = S corporation, P = Partnership). If this does not apply, please select N/A.*
Enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.
3b.

If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries. See instructions.
4. Exemptions (codes apply only to certain entities, not individuals; see instructions on W-9 page 3):

(Applies to accounts maintained outside the United States.)
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
5. Address*

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
7. List account number(s) here (optional)
Part I - Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter.
Social security number (one digit per box)
A
A
A
G
G
S
S
S
S
or Employer identification number (one digit per box)
X
X
X
X
X
X
X
X
X
Part II - Certification
Under penalties of perjury, I certify that
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
  Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
  no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
If you need to cross out item 2, please select "Cross out"
Signature of U.S. person*

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Date*

MonthDayYear
Date
For your reference only -- You can view the W-9 details and instructions below:

Direct Deposit Authorization

Contractors are limited to one bank.
I,Authorized Representative Name*, for Carrier Company Name* hereby:
authorize Coastline Connect Inc. and its agents, including financial institutions, to initiate electronic credit entries, and if necessary, debit entries and adjustments for any credit entries in error to my checking and/or savings accounts listed below. This authorization will remain in effect until I have informed Coastline Connect Inc. in writing that I wish to cancel it and Coastline Connect Inc. has had reasonable time to effect such cancellation. I understand I should contact my bank to verify receipt of funds.
Signature*

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Date

MonthDayYear
Date
Bank Name*
Bank Address
Bank Phone Number
Routing Number*
Account Number*
Account Type*

CheckingSavings
Please attach a voided check for the bank account to which funds will be deposited. Do not use deposit slip.

Cancelof
Notice: Government regulations have changed regarding the use of direct deposit. As a result, the company cannot offer direct deposit of funds to either:
- a foreign bank, or
- a U.S. financial institution where the entire amount will be forwarded to a bank account in another country.
Employees or contractors associated with such foreign organizations will not be eligible for direct deposit.

Insurance Certificates

Certificates must show Coastline Connect as additional insured
Certificate of Insurance - General Liability $1,000,000

Cancelof
EXPIRATION DATE - Certificate of Insurance - General

MonthDayYear
Date
Certificate of Insurance - Automobile Liability $1,000,000

Cancelof
EXPIRATION DATE - Certificate of Insurance - Automobile

MonthDayYear
Date
Certificate of Insurance - Cargo $100,000

Cancelof
EXPIRATION DATE - Certificate of Insurance - Cargo

MonthDayYear
Date
Certificate of Insurance - Workman’s Compensation $1,000,000 per occurrence (if applicable)

Cancelof
EXPIRATION DATE - Certificate of Insurance - Workers Comp

MonthDayYear
Date
Equipment Details
Feel free to use our Equipment List Template
Listing of equipment (tractors and trailers)

Cancelof
Copies of DMV Registration for all listed trucks or trailers

Cancelof
Copies of Air Resources Board Certificates for registered equipment

Cancelof
Authorized Driver Details
Feel free to use our Driver List Template
Listing of authorized drivers and hire dates (do not include DL#s or SS#s in this list)

Cancelof
Copies of valid CA Commercial Driver's License for all authorized drivers

Cancelof
Copies Medical Examiner’s Certificate for all authorized drivers

Cancelof
Should be Empty:

Carrier Package

Carrier Information

Authorized Company Officer

Dispatching

Billing

Incident / Accident Claims

Emergency Contacts

Broker - Carrier Agreement

Motor Carrier Certification of Compliance

W-9

Part I - Taxpayer Identification Number (TIN)

Part II - Certification

Direct Deposit Authorization

Insurance Certificates

Equipment Details

Authorized Driver Details