E&B / IB Subhauler Carrier Packet

Carrier Information      

• Company Name   
• Street Address
• Owner       Phone Number        
• Dispatcher       Phone Number     

5A. Consortium Motor Carrier to Motor Carrier Agreement (Company)
Carrier Name:   Name   
CA Number:   CA Number   
PLEASE CHECK (A) OR (B) AND SIGN THE CERTIFICATION, INCLUDE YOUR CAL‑T NUMBER IN THE SPACE PROVIDED BELOW AND RETURN AT ONCE TO THE ADDRESS STATED ABOVE.

A - I Certify that the above California Department of Transportation (DOT) regulated highway carrier DOES NOT EMPLOY any person in any manner so as to become subject to workers compensation laws of CA, and that if in the future the carrier does employ any person(s) in any manner so as to become subject to the workers compensation laws of CA I shall promptly file with the Commission and Broker a Certificate of Workers Compensation Insurance coverage or a certificate of consent to self‑insure issued by the Director of Industrial Relations. 

B - I Certify that the above California Department of Transportation (DOT) regulated highway carrier DOES EMPLOY person(s) in a manner so as to become subject to the workers compensation laws of CA and I shall promptly file with the Commission and Broker a Certificate of Workers Compensation Insurance coverage or a certificate of consent to self‑insure issued by the Director of Industrial Relations.

Certification
I certify that I have read and understand the above requirement regarding workers compensation and that I and the above named carrier are able to and will comply with it, and that the information I have provided on this form are true and correct to the best of my knowledge and belief. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature   First Name   Last Name      
Date   Company     CA #    

5B. Authorization for Release of Confidential Information (Owner Operator)

THIS IS TO CERTIFY THAT I,   First Name   Last Name   ,   AM AN INDEPENDENT CONTRACTOR, AND OPERATE MY BUSINESS AS AN OWNER OPERATOR FIRM. I DO NOT EMPLOY ANY DRIVERS ON MY TRUCKS. I AM NOT REQUIRED TO CARRY WORKER'S COMPENSATION ON MYSELF. I UNDERSTAND THAT I AM NOT INSURED FOR WORKER'S COMPENSATION BENEFITS UNDER THE POLICY OF E & B BULK TRANSPORTATION, INC., NOR UNDER THE POLICIES OF ANY OF THE CONTRACTORS WHOSE JOBSITES I MAY ENTER IN THE COURSE OF MY PERFORMING SUB HAUL SERVICES FOR E & B BULK TRANSPORTATION, INC. SHOULD I HIRE EMPLOYEES IN THE FUTURE, I WILL OBTAIN WORKER'S COMPENSATION TO COVER THOSE EMPLOYEES, AND I WILL PROVIDE A CERTIFICATE OF SUCH INSURANCE TO E & B BULK TRANSPORTATION, INC. PRIOR TO ASSIGNING ANY DRIVERS TO MY VEHICLE(S) UNDER THIS SUB HAUL AGREEMENT BETWEEN MYSELF AND E & B BULK TRANSPORTATION, INC.
Signature   First Name   Last Name  
Date   Company    CA #