Prime Coverage Group (PCG)

Driver's Online Application

Please complete the form below to apply for a position with us.
Thank you for your interest in Prime Coverage Group. To apply for a driving position, please complete our online application for employment. Incomplete information will delay the processing of your application or prevent it from being submitted.

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

To fill out this form, you will need to know the following and upload necessary paper work:
- Social Security Number
- Home address history for the past 3 years
- Current driver license number and driver license history for the past 3 years
- Employment history up to 10 years
- History of traffic accidents, violations and/or convictions from the last 3 years (including DUI or reckless driving conviction and license suspension)
- Military history (if applicable)
Required entry fields are followed by, meaning you must provide the requested information to continue. If you encounter any errors during this process and cannot continue, please contact us at 888-250-9575.

Requirements

To qualify with Prime Coverage Group, you must meet the following criteria:

Valid commercial license with proper endorsements in the state of residence:
- No current suspension or revocation
- Work permit is not acceptable
- A minimum of One and Half (1.5) years verifiable over the road experience
- No serious** or disqualifying traffic violations within the last three (3) years
- Excessive speeding, 15 mph over the posted speed limit
- Reckless driving
- Improper or erratic lane changes
- Following too close
- Hit and run
- No more than three (3) moving violations in the past three (3) years
- No more than one (1) moving violations in the past twelve (12) months
- Only one (1) DOT reportable accident within the past three (3) years
- No convictions for DWI for the past ten (10) years
- No positive results for a controlled substance
- No convictions for use, sale, or possession of any controlled substance
What position are you applying for?
Owner Operator Company name
Are you currently employed?
Have you ever worked for this company before?
How did you hear about us?
From where?
Recruiting Representative, if any

COMMERCIAL DRIVER APPLICATION

FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED--PRINT OR TYPE
Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Have you ever been known by any other name?
What name?
Address

Street Address

Street Address Line 2

CityState

Zip Code
If your above address is less than 3 years continue listing them below to cover the previous 3 year period:
Less than 3 Yes?
Address

Street Address

Street Address Line 2

CityState

Zip Code
Add more address?
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
SSN
Driver’s License Information: all licenses held, last 3 years:
License State
License Number
Date of original Issuance

MonthDayYear
Date
License Expiration

MonthDayYear
Date
Is this a commercial driver license?
License Class?
Second License?
License State
License Number
License Expiration

MonthDayYear
Date
Third License?
License State
License Number
License Expiration

MonthDayYear
Date

DRIVING EXPERIENCE

For each class of equipment, enter type of equipment (van, reefer, tank, etc.), start and end dates, and approximate number of total miles. If no experience in a class, enter "NONE".
Straight Truck
Tractor and Semi-Trailer
Tractor - Two Trailers
Refer
Flatbed
Others
EQUIPMENT (OWNER/OPERATORS ONLY)

Equipment Description (Tractor)
Type:
Current Vehicle Value:
Does this Vehicle need comprehensive or collision coverage?
Does this Vehicle have any permanently attached equipment (including aftermarket part, mounted equipment and modifications)?
Year:
Make:
Color:
VIN:
PERSONAL REFERENCES

List name, address, city, state, phone number, and relationship:
First Reference:
Second Reference:
In case of Emergency, notify (list name, address, and phone):

0/10

Experience:
Type of Vehicle
From

MonthDayYear
Date
Till

MonthDayYear
Date
Aprox. Mileage Driven
Add more experience?
Experience (2):
Type of Vehicle
From

MonthDayYear
Date
Till

MonthDayYear
Date
Aprox. Mileage Driven
Add more experience?
Experience (3):
Type of Vehicle
From

MonthDayYear
Date
Till

MonthDayYear
Date
Aprox. Mileage Driven
Any Accident in the last 3 years? If NONE, select "No"
Date

MonthDayYear
Date
Describe
Fatalities
Injuries

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective emp loyer, which may be done at anytime, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the
prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.

Certification
“I certify that this application was completed by me, and that all entries on it and information in it are true
and complete to the best of my knowledge.”
Date of Signature

MonthDayYear
Date
Applicant Signature
TO BE COMPLETED BY THE EMPLOYER:
Application received by:
Name
Title
Date
Date
Application reviewed for completeness by:
Name
Title
Date
Date
Date of Hire
Date of Hire
Time & Date of Pre-Employment CST:
Time & Date of Pre-Employment CST Results Received
Date First Used in Safety Sensitive Position:
Date of Termination::

COMMERCIAL VEHICLE DRIVER APPLICANT
Controlled Substance and Alcohol Questionnaire
Pursuant to 49 CFR part 40.25(j)

--------------------------------------------------------------
Application Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone

Area CodePhone Number
Cell Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
SSN
49 CFR 40.25(j)
Have you ever tested positive, or refused to test,on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
If YES — Have you successfully completed the return-to-duty process?
If YES — Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.
Date of Signature

MonthDayYear
Date
Applicant Signature
TO BE COMPLETED BY THE EMPLOYER:
Application received by:
Name
Title
Date
Date
Application reviewed for completeness by:
Name
Title
Date
Date

The Federal Motor Carrier Safety Regulations require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation of 49CFR 391.23 and 40.25, for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the Minnesota Division Office of the Federal Motor Carrier Safety Administration at 651-291-6150, during business hours.

TO:
Former Employers name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone

Area CodePhone Number
Fax

Area CodePhone Number
I, hereby authorize to release to all records of employment, including assessments of my job performance, ability, and fitness, including the dates of any and all alcohol or drug tests, with confirmed results, and/or my refusal to submit to any alcohol and drug tests and any rehabilitation completion under direction of Substance Abuse Professional (SAP) and/or Medical Review Officer (MRO) to each and every company (or their authorized agents) making such request in connection with my application for employment with said company. I, hereby, release the above named company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company.
Date of Signature

MonthDayYear
Date
Applicant Signature
REQUEST FROM:
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Applicant

First NameMiddle NameLast Name
SSN
Job Applying for
INQUIRY INTO EMPLOYMENT HISTORY, PRECEDING 3 YEARS

• Did applicant work for you as a

____________________________ from ____/____/____ to ____/____/____ YES or NO IF NO, please explain:

_______________________________________________________________________

• If employed as driver, please answer the following: Company

Driver? ______ Owner/Operator? ______ Other? ____________________________

Type of truck(s) and/or truck/tractor(s) operated:

_______________________________________________________________________

Commodities transported: ____________________________ Area of operations:

____________________________

• Accidents? YES or NO IF YES, please give date(s) and brief description of each accident:

_______________________________________________________________________

• Why did this employee leave your company?

_______________________________________________________________________

• Would you re-employ this person? YES or NO IF NO, please explain:

_______________________________________________________________________

• Additional comments:

_______________________________________________________________________
INQUIRY FOR ALCOHOL AND CONTROLLED SUBSTANCES INFORMATION, PRECEDING 2 YEARS

• Alcohol tests with a result of 0.04 or greater? ………. YES or NO If yes,

please give date(s): _______________________________________

• Verified positive controlled substances test results? … YES or NO If yes,

please give date(s): _______________________________________

• Refusals to be tested? ………………………………… YES or NO If yes, please

give date(s): _____________________________________________

• Was rehabilitation completed as required? …………... YES or NO If yes,

please give date(s): _______________________________________
Person providing the above information:
Name
Company
Title
Date

ANNUAL MOTOR VEHICLE DRIVER’S CERTIFICATION OF VIOLATIONS
Name

First NameMiddle NameLast Name
In accordance with 49 CFR 391.27, I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.
Date

MonthDayYear
Date
Offense
Location (City/State)
Type of Vehicle Operated
If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.
Date of Certification

MonthDayYear
Date
Driver's Signature

Unauthorized Passengers
Name

First NameMiddle NameLast Name
I understand that no passengers may ride in my tractor or in a company tractor without written authorization unless I am transporting someone to a clinic or hospital that needs immediate medical attention. I understand that the transportation of unauthorized passengers may result in the termination of my lease with Carrier and 1000$ fine.
Date

MonthDayYear
Date
Signature
I here authorize to obtain and send copy of my driving record to the address or fax number i have provided. I certify that all information provided by me pursuant to this agreement is true and accurate to the best of my knowledge and i have read, understand and agree to the terms of this agreement
Daytime Phone

Area CodePhone Number
Date

MonthDayYear
Date
Signature

Upload the below paperwork's

Please send the documents you couldn't upload via email to recruitment@primecoveragroup.com
Driver's License

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MVR*

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Medical Card

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Drug Test

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Truck Registration/(CABCARD)

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Truck Inspection

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Truck Insurance/BOBTAIL

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Trailer Registration

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Trailer Insurance

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Emission Test

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Trailer Inspection

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IRS Tax Pay Identification Document

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Voided Check/Bank Info

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W9

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ELD

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For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).
As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information

Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective emp loyer, which may be done at anytime, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up
or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.
Date

MonthDayYear
Date
Certification

“I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.”
Signature
Should be Empty:

Driver's Online Application

Upload the below paperwork's