Request for Utility Inspector Coordinator and RWIC Field Services on BNSF Right-of-Way

REQUEST FOR INSPECTOR COORDINATOR AND RWIC FIELD SERVICES
PERMIT APPLICATION / TRACKING REFERENCE NUMBER*
Ex: 20-12345 | Note: if your permit number only has 6 digits please enter a leading zero in the second set of numbers (e.g., for 20-1234, please enter 20-01234).
Today's Date:

MonthDayYear
Date
SECTION 1: PRE-PAYMENT INFORMATION
Instructions for Scheduling Inspector Coordinator and Roadway Worker in Charge (RWIC) Field Services:

(For assistance contact WilsonCompany.Utility.IC@Wilsonco.com or (816) 556-3624):

1. Complete this form and click submit. The information you provide will be used to generate a Pre-Payment Invoice (PPI) for Inspector Coordinator and RWIC services, which will follow receipt of this form.

2. Submit payment for the Pre-Payment Invoice (PPI). Payment instructions for payment by check and EFT will be attached to the Pre-Payment Invoice.

3. Scheduling your utility installation: Once you have received the final executed BNSF Agreement from JLL and the Pre-Payment Invoice is confirmed paid in full, Wilson & Company will schedule Inspector Coordinator and RWIC field services and confirm the installation/construction start date. Note that a minimum lead time of 15 days from confirmation of payment and initiation of the scheduling process is required to schedule all utility installations.

As a reminder, please ensure that all your employees and contractors who will be working on the utility installation/construction site on BNSF Railway property complete the required Safety Orientation Program at www.BNSFcontractor.com and have the valid badges as required under your permit. Personnel who are not able to display a valid badge and/or do not have appropriate PPE will not be allowed to access BNSF property. You are responsible for meeting the requirements of the license agreement.
PERMIT APPLICANT COMPANY:
APPLICANT CONTACT NAME:

First NameLast Name
UTILITY INSTALLATION AT/NEAR CITY AND STATE:
BNSF DIVISION*
Note: BNSF Division, subdivision, line segment and milepost can be found on your permit document.
BNSF SUBDIVISION*
Line Segment*
Milepost*
RESPONSIBLE PARTY FOR PAYMENT:

(For receipt of invoices)
COMPANY NAME:*
PAYMENT CONTACT NAME:*

First NameLast Name
ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER:*
EMAIL*
Note: The invoice for Inspector / RWIC services will be sent to this address.
SECTION 2: SCHEDULE INFORMATION
By submitting this form, the licensee acknowledges the following:*

Confirmed pre-payment is required before services will be scheduled. Note that a minimum lead time of 15 days from confirmation of payment and initiation of the scheduling process is required to schedule all utility installations.A positive balance of pre-paid inspection and/or RWIC days are required throughout the entire duration of the project to maintain continuation of services. If all prepaid days have been used, construction will be stopped and cancellation charges will be assessed accordingly. It is the licensee's responsibility to ensure that a sufficient number of days to complete construction have been fully funded.Requested start date is provided for informational purposes only to assist with beginning the Inspector Coordinator and RWIC scheduling process as required under the licensee’s executed license agreement.No work shall commence on BNSF right-of-way without the presence of a Wilson & Company Inspector Coordinator.
DESIRED START DATE REQUEST FOR INSTALLATION WITHIN BNSF RIGHT-OF-WAY:*

MonthDayYear
Note: Please plan for a minimum of 3 weeks of lead time from current date for payment processing and providing required project notices to BNSF division personnel. This date is not guaranteed and is not your start date until confirmed with a Wilson & Co scheduler.
Estimated number of project days: *
Days requiring access on, over, or under BNSF ROW
WORKING

SATURDAYSSUNDAYSN/A
DAILY START TIME*

:HourMinutesAM/PM Option
END TIME

:HourMinutesAM/PM Option
Est Daily Hours
ADDITIONAL SCHEDULING INFORMATION IF APPLICABLE:
FIELD COORDINATOR INFORMATION

(Field contact of applicant or applicant's contractor)
COMPANY NAME:
COORDINATOR CONTACT:

First NameLast Name
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER:
EMAIL
CONTRACTOR INFORMATION

(If different from applicant)
COMPANY NAME:
CONTRACTOR CONTACT:

First NameLast Name
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER:
EMAIL
Is this utility overhead or underground or a non-utility permit?*

OverheadUndergroundNon-Utility Permit
What kind of work will this non-utility permit pertain to? This may require additional review before an invoice is sent out.*

Survey WorkRoadway ResurfacingInspection WorkOther
Will this contractor be installing the carrier pipe/fiber optic cable?*

YesNo
An inspector is required by BNSF to be on site during the installation of the carrier pipe/fiber optic cable. Have you requested enough days to complete the installation?*

YesNo
Who will be installing the carrier pipe/fiber optic cable?*
Company Name
Company Contact:*

First NameLast Name
PHONE NUMBER:*
Scheduling of installation & field services will be initiated upon confirmation of payment and verification of compliance with all BNSF requirements. No work shall commence on the BNSF right-of-way without the presence of a Wilson & Company Inspector Coordinator.

A positive balance of pre-paid inspection and/or RWIC days are required throughout the entire duration of the project to maintain continuation of services. If all prepaid days have been used, construction will be stopped and cancellation charges will be assessed accordingly. It is the licensee's responsibility to ensure that a sufficient number of days to complete construction have been fully funded.
Confirmation email*
Email address to receive confirmation of form receipt
(A green check mark will be displayed after clicking the submit button to confirm successful form submission)
Number of Days
Project Implementation Fee
RWIC Days
OT Hours
Daily Hours
Inspector Days Charge
Inspector OT Charge
RWIC Days Charge
RWIC Daily Hours
RWIC OT Charge
Inspector Subtotal
RWIC Subtotal
Invoice Total
RWIC OT Hours
Should be Empty:

REQUEST FOR INSPECTOR COORDINATOR AND RWIC FIELD SERVICES

SECTION 1: PRE-PAYMENT INFORMATION

RESPONSIBLE PARTY FOR PAYMENT:

SECTION 2: SCHEDULE INFORMATION

FIELD COORDINATOR INFORMATION

CONTRACTOR INFORMATION