Customer Application Form (Page 2 of 3) in pdf

Page 2

CUSTOMER APPLICATION FORM (CONT.)

TAX STATUS:

Is your business tax exempt? YES ___________

NO ____________

If claiming tax exempt, you must provide a Tax Exemption Certificate acceptable to All Ways Leasing, LLC

HAZARDOUS MATERIAL

Are you a transporter of hazardous material, refuse or waste hauler as regulated by Motor Carrier Act 1980? YES ___________ NO ____________

If yes, and MC-990 endorsement must be on your auto liability policy.

Specify the type of material, refuse or waste your company hauls:______________________________________

INSURANCE REQUIREMENTS

Liability Insurance: All Ways Leasing, LLC must be listed as additional insured and loss payee. Minimum liability coverage required.

Commercial General Liability - $1 Million

Auto Liability - $1 Million

Please provide the following information:

Insurance Agency/Carrier name:_______________________________________________

Contact Name: _________________________________________________ Phone Number: (Please include area code): _____________________________

Physical Damage

Option A

All Damage Waiver (ADW)/Fire Theft Waiver (FTW)

All Ways Leasing, LLC will provide a price quote based on my company's equipment requirements.

Option B

Customer Provided Insurance

(Please provide the following Information:)

Insurance Agency/Carrier name:_______________________________________________

Contact Name: ________________________________________________ Phone Number: (Please include area code): ______________________________

REFERENCE INFORMATION

Bank and Trade references (Please list equipment references - rent, lease or finance.)

Bank Name: ___________________________________________________

Street Address: ____________________________________________________

City, State and Zip Code: ____________________________________________

Account #: ________________________________________________________

Contact: __________________________________________________________

Phone (Include Area Code): ___________________________________________

Brief Description of Reference:________________________________________________________________

_________________________________________________________________________________________

Customer Application Form Page 2