DBA (Doing Business as Name) *
Corporate Name *
Website
Contact First Name (Owner) *
Contact Last Name *
Email Address*
Line 1 *
Line 2
Line 3
City *
Zip *
Office Phone* ext
Dispatch Phone (24-hour if available)* ext
Fax Number ext
Business Cell Phone ext
Open 24 X 7* Yes No
Monday to
Tuesday to
Wednesday to
Thursday to
Friday to
Saturday to
Sunday to
DOT Number
Motor Carrier Number
Do you perform pre-employment background checks?
Do you perform random drug testing?
Do you have uniformed drivers?
Do all your service vehicles display the company name?
Electronic / Digital Dispatch
Fax
Email
Text
Cash
Personal Check
Visa
MasterCard
American Express
Discover
Total Number of Service Vehicles
Maximum GVW you can tow*
Is overnight stay allowed?
Do you cross state lines? Yes No
Do you cross international borders? Yes No
Please provide us a list of zip codes you cover. Please identify which zip codes you can cover within 45 minutes and those that take over 45 minutes to respond.
Primary: zip codes covered in less than 45 mins
Secondary: zip codes covered in over 45 mins
What towing software do you use?
Other Description
Do you currently use digital dispatch? Yes No Don't know
What software do your drivers use?
What GPS devices do your drivers use?
Request for Taxpayer Identification Number and Certification (W-9) As you know, Pinnacle Motor Club will need your W-9 information for federal tax reporting. Information sent from this website is encrypted and you can securely provide your W-9 electronically using the form below. However, if you are an individual (not a business) and prefer not to submit your SSN electronically, you can manually complete a W-9 Form and fax it to 800-331-1145. Click here for a W-9 Form
Individual/sole proprietor or single-member LLC
C Corporation
S Corporation
Partnership
Trust/estate
LLC - C Corporation
LLC - S Corporation
LLC - Partnership
Other
If this is corporation, LLC or other business entity, please provide your federal Employer Identification Number (EIN). If this is an individual and not a business, please provide your Social Security Number (SSN).
Employee Identification Number (EIN)*
Social Security Number (SSN)
Electronic Signature (type your name) *
Insurance Carrier Name*
Phone Number* ext
We must have a copy of your current certificate of insurance to maintain on file.
Pinnacle Motor Club must be listed as an Additional Insured on the certificate.
Include your Service Provider/Vendor ID # on the insurance certificate.
If you have an electronic copy of your insurance certificate, please upload the file below:
Upload Certificate of Insurance
If you do not have an electronic copy, please fax or mail a copy.
Fax : 800-331-1145
Mail : Service Provider Department. P.O. Box 1179, Grapevine, TX 76099-1179
* I have read the terms and conditions. *Click here to view the terms and conditions
IN WITNESS WHERE OF, this Agreement has been executed by the duly authorized representatives of the parties hereto as of the date accepted and executed by Pinnacle Motor Club as set forth below.
Title *
Comments *