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Company Information
Name
Company Type
Trucking
ILA
Contractor
Other
Address 1
Address 2
City
State
Zip
Country
USA
CAN
Phone Number
Fax
Primary Company Representative
First Name
Last Name
Email
Phone Number
Risk Management Information
Are you the sole proprietor?
Yes
No
Commission Entity ID Number
Are you directly contracted by a VPA, VIT, or HRCPII contract?
Yes
No
VPA, VIT, or HRCPII Contract Number
Sponsor
Virginia Port Authority (VPA)
Virginia International Terminals (VIT)
Hampton Roads Chassis Pool (HRCPII)
Cooper/T. Smith and Ports America (CP&O)
CrossGlobe Transport, Ltd
ITS ConGlobal
JAZ Enterprises (JAZ)
Marine Repair Services Container Maintenance Corporation (MRS-CMC)
Scoular Grain
TTX
Authorized Food Truck Vendor
Other
Sponsor Company Name
Sponsor First Name
Sponsor Last Name
Sponsor Email Address
Sponsor Phone Number
Business Activity Category
Building Contractor / Construction Projects
Consultants / Professional Services Provider: Law Firms, Architects, Environmental Consultants, Engineers, Security Companies, Accountants, Investment Managers and Insurance Brokers, Marine Surveyor, Surveyor, Ships Agent
Cyber, Technology Products and Services
Environmental Contractors / Fuel Service / Oil Service / Hazardous Material Vendor / Vessel Repair, Cleaning Service (Chemicals)
General Suppliers and/or Vendors
Maintenance Contractors / Tradesmen (Crane Maintenance, Vehicle Maintenance, Facility Maintenance
Other
Scope of Work / Reason for Access (Limit 1000 Characters)
Insurance - check all that apply:
General Liability (Minimum Required: $1MIL Occurrence / $2MIL Aggregate)
Yes
No
Please Complete The Following For Your General Liability Policy
General Liability Each Occurrence Limit
General Liability Aggregate Limit
General Liability Policy Effective Date
General Liability Policy Expiry Date
General Liability Policy Number
General Liability Addl Insd
Yes
No
General Liability Subr Wvd
Yes
No
General Liability Insurer
General Liability NAIC Number
Commercial Auto Liability (Minimum Required: $1MIL Combined Single Limit (Each Accident))
Yes
No
Please Complete The Following For Your Commercial Auto Liability Policy
Commercial Auto Liability Combined Single Limit
Commercial Auto Liability Policy Effective Date
Commercial Auto Liability Policy Expiry Date
Commercial Auto Liability Policy Number
Commercial Auto Liability Addl Insd
Yes
No
Commercial Auto Liability Subr Wvd
Yes
No
Commercial Auto Liability Insurer
Commercial Auto Liability NAIC Number
Umbrella Liability (No Limits Required)
Yes
No
Please Complete The Following For Your Umbrella Liability Policy
Umbrella Liability Each Occurrence Limit
Umbrella Liability Aggregate Limit
Umbrella Liability Policy Effective Date
Umbrella Liability Policy Expiry Date
Umbrella Liability Policy Number
Umbrella Liability Addl Insd
Yes
No
Umbrella Liability Subr Wvd
Yes
No
Umbrella Liability Insurer
Umbrella Liability NAIC Number
Worker's Compensation (Minimum Required: Per Statute & $1MIL Employer's Liability)
Yes
No
Please Complete The Following For Your Worker's Compensation / Employer's Liability Policy
Per Statute
Other
Workers Compensation / Employer's Liability Per Statute Limit
Workers Compensation / Employer's Liability Other Limit
Employer's Liability Accident Limit
Employer's Liability Disease Limit
Employer's Liability Policy Limit
Worker's Compensation / Employer's Liability Policy Effective Date
Worker's Compensation / Employer's Liability Policy Expiry Date
Worker's Compensation / Employer's Liability Policy Number
Worker's Compensation / Employer's Liability Insurer
Worker's Compensation / Employer's Liability NAIC Number
Unlisted Policy Type
Yes
No
Terminal Access Agreement
Terminal Access Agreement
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