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Environmental, Health, and Safety Motor Carrier Prequalifications Form

Form Guidance

General Information

You have landed on this page because you've selected Hire by Koch and/or Access Koch Facilities from the New Carrier Request form. Please fill out the form and submit it along with the new carrier request form.

Motor Vehicle Accident Rate

The Accident Rate is calculated by dividing the number of DOT Reportable Accidents that year by the number of million miles that were traveled during that same time.

Number of accidents ? Number of million miles = Accident Rate per million miles

For example: 2 accidents ? 3.0 million miles = 0.66 accidents per million miles

Generally, a DOT Reportable Accident is any accident involving a commercial motor vehicle and a:
  • Fatality
  • Injury treated away from the scene
  • Any vehicle tow-away

  • OSHA 200/300 Total Recordable Incident Rate

    The Recordable Incident Rate is calculated by dividing the number of OSHA Recordable Incidents during a year by the actual total employee work-hours during that same time. Incident Rates are calculated and reported on the basis of 200,000 work hours per year which is equivalent to 100 full-time workers (100 x 40hr/wk x 50 wk/yr).

    Number of incidents ÷ number of work-hour X 200,000 = Incident Rate

    For example: 3 incidents ÷ 251,645 work-hours X 200,000 = 2.4 incidents per 100 employees

    If work hours are not available, the OSHA Incident Rate can be approximated using the number of employees.

    For example: 3 incidents ÷ 127 employees X 100 = 2.4 incidents per 100 employees

    Employers with less than 10 employees may be partially exempt from OSHA Recordkeeping requirements. Additional information on OSHA’s Rec

    Company Overview

    A-1 Please provide FMCSA/HMSP/DOT Authority Numbers (as applicable).

    Motor Carrier (MC) Number
    DOT Number
    Hazardous Materials Safety Permit ID & Exp. Date
    State Authorities (list all that apply)

    A-2 How many units do you own and lease?

    Number Owned Average Number Leased Highest Number Leased
    NH3 Ammonia
    Hopper Bottom

    A-3 Have you ever had an on-site DOT Safety Compliance Review?

    Yes No

    What is the date of the most recent DOT Compliance Review?

    A-4 What is your DOT Motor Carrier Safety Rating?

    Satisfactory Conditional Unsatisfactory Not Rated

    A-5 Do you have a written safety policy?

    Yes No

    A-6 How many millon miles were driven during each of the last three years?

    Year Miles Driven

    A-7 What was your motor vehicle accident rate during each of the last three years?
    (For help, see Form Guidance)

    Year Accident Rate

    A-8 What was your OSHA 200/300 recordable incident rate during each of the last three years?
    (For help, see Form Guidance) - If not applicable, please indicate why.

    Year OSHA 200 Recordable Incident Rate OSHA 300 Recordable Incident Rate

    A-9 How many spills/releases were reported on DOT Form 5800.1 during each of the last three years?

    Year Spills Accident Rate Releases Accident Rate

    A-10 Has your company re-organized/shipped under a different company name within the last 5 years?

    Yes No

    If yes, list the date of reorganization: and list previous company name, DOT#, and/or MC# if different than current:
    Emergency Planning

    B-1 List your company's contact for transportation-related emergencies:

    Job Title
    Telephone # (Business Hours)
    24-hour Emergency Telephone #

    B-2 Is a contracted service used by your company for incident response and/or emergency response? (This service may be provided by your insurance company)

    Yes (Company: )

    B-3 Detail your company's procedure for ensuring notification of our company, in the event of any incident involving our product.

    B-4a Are drivers and shipments monitored during transit (tracking system/scheduled communication via phone/etc.)?

    Yes (Method & Frequency: )

    B-4b If shipping DOT Hazmat, do you meet the requirements of 49CFR172.802(a)(3) for enroute security?

    N/A (non-hazmat only carriers)

    B-5 If shipping DOT Hazmats, does your driver vetting process meet the requirements of 49 CFR 172.802(a)(1)

    N/A (non-hazmat only carriers)

    B-6) Transportation Security (49 CFR 172.80) (Applicable only to hazardous materials shipments. Others should mark N/A)

    Yes No N/A
    Has your company implemented a written security plan that complies with the requirements of 49 CFR 172.800 and 172.802? Yes No N/A
    Have employees received security awareness training (49 CFR 172.704(a)(4))? Yes No N/A
    Have employees received in-depth security training (49 CFR 172.704(a)(5))? Yes No N/A


    C-1) What are your insurance limits on a per occurence basis? Complete the table below indicating your applicable limits.

    Automobile General Liability
    Primary Limits
    Training and Procedures

    For each load-specific category, indicate if Driver Training complies with all applicable regulations governing the material hauled and whether Written Procedures are in place that comply with all applicable hazardous materials regulations.

    Load Specific Categories Driver Training Written Procedures
    These grouping are different than the 9 hazard classes defined by DOT Indicate Yes or No Indicate Yes or No
    D-1 Non-regulated Materials
    (Examples: Aggregate, Protland Cement, UAN, Urea, PIA, TMA, Polymers)
    Yes No Yes No
    D-2a Elevated Temperature Liquid, Flammable
    A flash point greater than 100F; shipped at or above the flash temperature
    Yes No Yes No
    D-2b Elevated Temperature Liquid
    A liquid shipped at or above 212F but below its flash point
    Yes No Yes No
    D-3 Hazardous Materials
    Not included in Categories D-2 (above) or D-4 (below). (Examples: Gasoline, Flammable Liquids, PGII Acids, Expandable Polystyrene)
    Yes No Yes No
    D-4 Hazardous Materials
  • Liquefied Compressed Gases
    (Examples: Anhydrous Ammonia, Ethane, Propane)
  • Corrosive PG I Materials (Example: HF)
  • Any materials with high potential for inhalation exposure requiring respirators to load/unload (Example: PIH's)
  • Yes No Yes No
    Provide the numbers of years experience handling D-4 Type loads No. of Years

    Person responsible for providing the information contained in this survey:

    Telephone Number:
    Email Address:

    Survey was completed by:

    If completed by the responsible person, check here..
    Telephone Number:
    Email Address:

    Please email copies of a W9 and a blank invoice to one of the following addresses;
    Dry Products:
    NH3/Liquid Products:

    To receive ACH payments directly to your bank, please complete the following forms and return with your W9 and Blank Invoice.

    ACH/EFT Authorization Information

    Wire Authorization Information

    Thank you for taking the time to fill out the form. A representative will contact you if any further documentation is needed.

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