Carrier Intake

Carrier Intake Application

Complete this form to begin dispatch services under your own authority. Upload required documents to avoid delays.

Business Information

Legal Business Name *

DBA

MC Number *

DOT Number *

EIN (Last 4)

Years in Business

Primary Contact Name

Phone

Email *

Business Address

Equipment Type

Truck (Year/Make/Model)

Trailer (if applicable)

Max Capacity

Liftgate

Pallet Jack

Securement (Straps/Chains/Bars)

No-Go States

Preferred Lanes / Regions

Home Time Requirements

Minimum Rate Per Mile

Target Weekly Gross

Fee Structure Preference

Insurance Company

Agent Name

Agent Phone

Agent Email

Do you use factoring?

Factoring Company

Factoring Contact Email

Certificate of Insurance (COI) Tip: COI should list PrimeLane as Certificate Holder.

W-9

Voided Check

Operating Authority / MC Letter

Notes

PrimeLane Carrier Solutions provides dispatch services and does not act as a motor carrier, broker, or freight forwarder.