BEST IN TOW PROGRAM APPLICATION Evaluation Period: June 30, 2023 - June 30, 2024 Submissions must be received by August 31, 2024
APPLICANT INFORMATION Business Name _________________________________________ Owner Name___________________________________________
DBA_ ______________________________________ DOT #_ ____________________________________
Principal Contact________________________________________ MC #_ _____________________________________ Address_____________________________________________________________________________________________ Phone Number__________________________________________ Agency _ ___________________________________ VEHICLES Total Number of Units __________________________________________________________________________________ Fleet Breakdown: _________ Extra Heavy _________Heavy _________ Mediums _ ________ Lights _ _______ PPTs DRIVERS Number of Drivers (as of 6/30/24) _ _______________________________________________________________________ WORKERS’ COMPENSATION Total Annualized Payroll _ _______________________________________________________________________________ Current e-Mod________________________________________________________________________________________
QUESTIONAIRRE
Yes
No
1. Are you a member of the Towing & Recovery Hall of Fame? a. If Yes, please describe your involvement:
o o
2. Does your organization currently have a safety program in place? a. If Yes, please describe:
o o
The undersigned authorized representative of Applicant declares that the information set forth in this application is true and accurate to the best of their knowledge. The Applicant understands and agrees that if the information submitted on this application changes between the date of submission and August 31, 2024, Applicant will notify National Interstate Insurance Company (“National Interstate”) immediately of such changes. If it is determined that any information submitted is false, misleading, or inaccurate, National Interstate reserves the right to disqualify Applicant from eligibility in receiving an award under the Best in Tow Program.
Signature ____________________________________________ Name ________________________________________ Title _ ____________________________
See official program rules on the following page.
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