Account Maintenance Form - Nys Department Of Transportation
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1
2(04/14)
VERSION
NYS D
T
EPARTMENT OF
RANSPORTATION
ACCOUNT MAINTENANCE
C
P
O
ENTRAL
ERMIT
FFICE
ST
50 W
R
, 1
F
N
OLF
OAD
LOOR
ORTH
A
, N
Y
12232
Reset Form
Instructions
LBANY
EW
ORK
(518) 485-2999
1-888-783-1685
TOLL FREE
V
:
.
.
ISIT OUR WEBSITE
WWW
NYPERMITS
ORG
N
C
– Complete all applicable information.
EW
USTOMER
A
U
– C
N
:____________
CCOUNT
PDATE
USTOMER
O
* F
U
,
OR
PDATE
ENTER ONLY THE NEW INFORMATION
A
C
– C
N
:____________ R
:_______________________
CCOUNT
LOSURE
USTOMER
O
EASON
Company Name:
DBA:
USDOT #
FEIN #
:
P
A
HYSICAL
DDRESS
Street Address:
City & State:
Zip:
M
A
:
(If different than above)
AILING
DDRESS
Street/PO Box Address:
City & State:
Zip:
You are required to check the type of Worker's Compensation and Disability Insurance that will be in effect for the
duration of all issued OS/OW permits.
Worker's Compensation
Disability Insurance
Self
Self
Group
Group
Exempt
Exempt
You are required to check the Insurance coverage limit that will be in effect
for the duration of all issued OS/OW permits.
$750,000.00 Bodily Injury or Death in any one accident & $250,000.00 injury to or destruction of property in any one accident.
$1,000,000.00 combined Single Liability coverage for any one accident.
Undertaking – Municipalities and Government Agencies ONLY.
Contact Person:
Name:
Work #
Cell #
Fax #
E-Mail:
Permit Service Submittal Acknowledgement
YES
I agree to allow Permit Service Companies to submit applications on behalf
NO
o
f the company as indicated by name and or customer number above.
AFFIRMATION
False statements made on this application are punishable as a crime under Penal Law section 210.45
Authorized Representative Signature:______________________________________ Date:___________
(Type or Write)
You may return the completed form by e-mail to:
permits@dot.ny.gov
Or Fax to: 518-457-1036
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