Blue Bills, LLC Dispatcher Questionnaire
Carrier Profile
Customer Details:
Company Name
*
DBA (If Any)
Full Name
*
First Name
Last Name
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
DOT #
*
Motor Carrier #
*
SSN # or EIN #
*
TWIC Card
Please Select
Yes
No
HAZMAT Certified (If yes, please provide HAZMAT certification PDF or training certificate
Please Select
Yes
No
Equipment (All flatbeds must have their own securement equipment to include tarps)
*
48' Van/Reefer
53' Van/Reefer
Flatbed
Stepdeck
Hotshot
Boxtruck
Other
Check All that Apply
Air ride
Pallet jack
Dolly
Straps/Binders
Tarps
Lift gate
Dock high
PPE Equipment
Truck #
Trailer #
Max Load Weight
*
Where would you like to travel?
Trailer Width
Truck Dimensions (ONLY Box Truck, Vans & Reefers L x W x H)
Cost per mile (Total monthly expenses/Miles per month + Average cost of 1 gallon of fuel/Miles per gallon your truck averages = Cost per mile)
Factoring Company
Factoring Company's Phone Number
Factoring Company's Email
example@example.com
Factoring Company's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Factory Company's Username (for us to submit your docs)
Your Factory Company's Password (for us to submit your docs)
Insurance Company
Insurance Company's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company's Email (for Insurance Certificate requests)
example@example.com
Signature
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Should be Empty: