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Indiana Business Authorization And Safety Application For Intrastate And Or Interstate Carriers BAS-1 - Indiana
| Indiana Business Authorization And Safety Application For Intrastate And Or Interstate Carriers Form. This is a Indiana form and can be used in Motor Carrier Department Of Revenue Statewide . |
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FORM BAS-1 State Form 46918 (R4 / 10-12 ) Indiana Business Authorization and Safety Application for Intrastate and/or Interstate Carriers for Calendar Year _______ Indiana Department of Revenue For Department Use only Renewal (Due November 30th) New Applicant Information Change All motor carriers are required to obtain and/or renew a USDOT Number or Indiana ID number. Read the instructions before continuing. Section A: Motor Carrier Information 1. Legal Name 2. Doing Business As (DBA) Name 3. Physical Street Address 4. Mailing Address (If Different From Street Address) 5. City 6. State/Province 7. Zip Code 8. City 9. State/Province 10. Zip Code 11. County 12. Principle Phone No. 13. Cell Phone No. 14. Fax Number 15. County 16. TID Number 17. FEIN/SSN 18. USDOT/Indiana ID Number 19. FHWA/MC Number 20. Internet E-Mail Address Section B: Type of Motor Carrier Operation 21. Carrier Operation (Check All That Apply) A. Interstate (Hazardous Materials) C. Intrastate (Non-Hazardous Materials) 22. Shipper of Hazardous Materials operation (Check One) A. Interstate (Includes traveling outside Indiana) B. Intrastate (Traveling within Indiana only) 24. Operation Classification (Check All That Apply) A. B. C. B. Intrastate (Hazardous Materials) D. Interstate (Non-Hazardous Materials) 23. Carrier Mileage (To nearest 10,000 miles for Last Calendar Year) _____________________________________________________________ Authorized For-Hire(Hauling someone else's product/passengers in your vehicle) Exempt For-Hire (Hauling someone else's exempt product in your vehicle.) This applies to only J, O, P, S, T & AA (As listed below) E. F. Private Passengers (Non-Profit) (This would apply to Church Buses, etc.) Broker Intrastate Household Goods & Passenger Private (Property) (Hauling your own product in your vehicle) D. Private Passengers (Business) (This would apply to Touring Bands, etc.) 25. Cargo Classifications (Please Check All That Apply) A. General Freight B. G. H. I. J. K. L. Household Goods C. Metal, Sheets, Coils, Rolls D. Motor Vehicles E. F Building Materials Mobile Homes Machinery, Large Objects M. N. O. P. Q. R. S. Driveaway/Towaway Logs, Poles, Beams, Lumber Fresh Produce Liquids/Gases Intermodal Cont. Passengers Oilfield Equipment Livestock Grain, Feed, Hay Coal/Coke Meat Garbage, Refuse, Trash T. V. U. Chemicals U.S. Mail Commodities Dry Bulk W. Refrigerated Food X. Beverages Y. Paper Products Z. Utility Farm Supplies Construction CC. Water Well DD. Other _______ AA. BB. American LegalNet, Inc. www.FormsWorkFlow.com 26. Hazardous Materials Carried or Shipped (Please Circle All That Apply) C (Carried) S (Shipped) B (Bulk)-In Cargo Tanks NB (Non-Bulk)-In Packages (Divisions that are in bold require 5,000,000 in insurance.) C C C C C C C C C C C C C C C C C C C C C S S S S S S S S S S S S S S S S S S S S S A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. T. U. Division (Class A) Division (Class A & B) Division (Class B) Division (Class C) Division Division Division Division Division Division Division Division Division Division Division Class Class Class Combustible Liquid Division Division 1.1 B 1.2 B 1.3 B 1.4 B 1.5 B 1.6 B 2.1 B 2.1 B 2.1 B 2.2 B 2.2A B 2.3A B 2.3B B 2.3C B 2.3D B 3 B 3A B 3B B B 4.1 B 4.2 B NB NB NB NB NB NB NB NB NB NB NB NB (Explosives) (Explosives) (Explosives) (Explosives) (Blasting Agents D) (Explosives N) (Flammable Gas) (LPG - Liquid Petroleum Gas) (Methane - Methane Gas) (Oxygen & Non Flammable Gas) (Anhydrous Ammonia) (Poison Gas which is Poison Inhalation Hazard (PIH) Zone A) (Poison Gas which is (PIH) Zone B) (Poison Gas which is (PIH) Zone C) (Poison Gas which is (PIH) Zone D) (Flammable Liquids) (Flammable Liquids which is (PIH) Zone A) (Flammable Liquids which is (PIH) Zone B) C C C C C C C C C C C C C C C C C C C C S S S S S S S S S S S S S S S S S S S S V. W. X. Y. Z. AA. BB. CC. DD. EE. FF. GG. HH. II. JJ. KK. LL. MM. NN. OO. Division Division Division Division Division Division Division Division Class HRCQ Class Class Class Class Elevated Temp Mat Infectious Waste Marine Pollutants Hazardous Sub (RQ) Hazardous Waste ORM-D 4.3 5.1 5.2 6.2 6.1A 6.1B 6.1 6.1 7 B B B B B B B B B B B B B B B B B B B B NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB NB (Dangerous) (Oxidizer) (Organic Peroxide) (Infectious Substance) (Poison Liquid which is (PIH) Zone A) (Poison Liquid which is (PIH) Zone B) (Poison Liquid with no inhalation hazard) (Solid-Poison Solids) (Radioactive) (Highway Route Controlled Quantity of Radioactive Material) (Corrosive Liquids) (Corrosive Liquids which is (PIH) Zone A) (Corrosive Liquids which is (PIH) Zone B) (Miscellaneous) NB NB NB NB NB NB NB NB (Flammable Solid) NB (Spontaneously Combustible) 8 8A 8B 9 27. Equipment Straight Trucks Truck Tractors Trailers HazMat Cargo Tank Trucks HazMat Cargo Tank Trailers Number of Passengers (including the driver) Motor Coaches 1-8 School Buses 9-15 16+ Minibus 16+ 1-8 Vans 9-15 1-8 Limousines 9-15 16+ Owned Term Leased Trip Leased 28A. Driver Information Within 100-Mile Radius Beyond 100-Mile Radius 28B. What is the Gross Vehicle Weight Rating on your vehicles. (Check all that apply) Interstate Intrastate Total Drivers Total CDL Drivers GVWR 29. Individual Name: Address: 26,001 - Over GVWR 17,001 to 26,000 GVWR 10,001 to 17,000 Section C: Business Type Name: Address: GVWR Under 10,000 LLC (list names, addresses) Name: Address: Partnership (list names, addresses) Name: Address: Corporation (list names, addresses) American LegalNet, Inc. www.FormsWorkFlow.com 30. Proof of Public Liability Security (check one) If you are an Intrastate For-Hire carrier and/or a Private Hazardous Materials carrier you must file a Form E Indiana insurance filing. You will need to request this filing from your insurance company. If you have active FHWA/MC authority you do not have to submit the Form E filing. Effective Date: Policy Number: Insurance Company Name: A. The applicant is a private carrier of non-hazardous materials or a private carrier of passengers and is not required to file proof of insurance with this form. B. The applicant is filing, or causing to be filed, a copy of its proof of public liability security in accordance with 49 CFR Part 1043 for transportation of nonC. The applicant is filing, or causing to be filed, a copy of its proof of public liability security in accordance with 49 CFR Part 1043 for transportation of nonhazardous materials with the minimum amount of $750,000 coverage. m
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