FORM BAS-1 Indiana Department of Revenue Indiana Business Authorization and Safety Application for Intrastate and/or Interstate Carriers for Calendar Year _______ State Form 46918 (R3 / 5-11) 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 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 10. Zip Code 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) B. ☐ Intrastate (Hazardous Materials) C. ☐ Intrastate (Non-Hazardous Materials) D. ☐ Interstate (Non-Hazardous Materials) 23. Carrier Mileage (To nearest 10,000 miles for Last Calendar Year) 22. Shipper of Hazardous Materials operation (Check One) A. ☐ Interstate (Includes traveling outside Indiana) _____________________________________________________________ B. ☐ Intrastate (Traveling within Indiana only) A. B. ☐ Authorized For-Hire(Hauling someone else’s product/passengers in your vehicle) ☐ Exempt For-Hire (Hauling someone else’s exempt product in your vehicle.) E. F. ☐ ☐ Broker Intrastate Household Goods & Passenger This applies to only J, O, P, S, T & AA (As listed below) ☐ Private (Property) (Hauling your own product in your vehicle) D. ☐ Private Passengers (Business) (This would apply to Touring Bands, etc.) C. A. ☐ General Freight G. B. H. ☐ Household Goods C. ☐ Metal, Sheets, Coils, I. Rolls Objects D. ☐ Motor Vehicles J. E. K. F ☐ Driveaway/Towaway ☐ Logs, Poles, Beams, ☐ Building Materials ☐ Mobile Homes ☐ Machinery, Large L. ☐ Fresh Produce ☐ ☐ Intermodal Cont. M. N. O. P. Q. S. ☐ Passengers ☐ ☐ Livestock ☐ Grain, Feed, Hay ☐ Coal/Coke ☐ Meat ☐ Garbage, Refuse, Trash ☐ U.S. Mail ☐ Chemicals V. ☐ Commodities Dry Bulk W. ☐ Refrigerated Food X. ☐ Beverages Y. ☐ Paper Products Z. ☐ Utility T. ☐ Farm Supplies ☐ Construction CC. ☐ Water Well DD. ☐ Other _______ AA. BB. Lumber 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 S S S S S S S S S S S S A. B. C. D. E. F. G. H. I. J. K. L. Division (Class A) 1.1 B Division (Class A & B) 1.2 B Division (Class B) 1.3 B Division (Class C) 1.4 B Division 1.5 B Division 1.6 B Division 2.1 B Division 2.1 B Division 2.1 B Division 2.2 B Division 2.2A B Division 2.3A B C C C C C C C C C C C S M. Division C S N. Division C S O. Division (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) 2.3B B NB (Poison Gas which is (PIH) Zone B) 2.3C B NB (Poison Gas which is (PIH) Zone C) 2.3D B NB (Poison Gas which is (PIH) Zone D) C S T. Division C S U. Division 4.1 B NB (Flammable Solid) 4.2 B NB (Spontaneously Combustible) Straight Trucks NB NB NB NB NB NB NB NB NB NB NB NB Truck Tractors Trailers Division Division Division Division Division Division Division Division Class HRCQ 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 C S II. C S JJ. Class Elevated Temp Mat 9 B NB (Miscellaneous) B NB C S OO. HazMat Cargo Tank Trucks ORM-D HazMat Cargo Tank Trailers S S S S S S S S S S V. W. X. Y. Z. AA. BB. CC. DD. EE. 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) B NB Number of Passengers (including the driver) Motor Coaches School Buses Minibus 9-15 16+ 1-8 16+ Vans 1-8 Limousines 9-15 1-8 9-15 16+ Owned Term Leased Trip Leased 28A. Driver Information Interstate Intrastate Total Drivers Total CDL Drivers Within 100-Mile Radius Beyond 100-Mile Radius 28B. What is the Gross Vehicle Weight Rating on your vehicles. (Check all that apply) ☐ GVWR 29. ☐ Individual 26,001 - Over ☐ ☐ GVWR 10,001 to 17,000 Section C: Business Type GVWR 17,001 to 26,000 ☐ Partnership (list names, addresses) ☐ GVWR Under 10,000 ☐ Corporation (list names, addresses) ☐ LLC (list names, addresses) Name: Name: Name: Name: Address: Address: Address: Address: American LegalNet, Inc. www.FormsWorkFlow.com 30. Proof of Public Liability Security (check one) authority you do not Policy Number: Effective Date: Insurance Company Name: A. ☐ B. ☐ hazardous materials with the minimum amount of $300,000 coverage for operating only vehicles having a Gross Vehicle Weight Rating (GVWR) of 10,000 pounds or less. C. ☐ hazardous materials with the minimum amount of $750,000 coverage. D. ☐ ous materials with the minimum amount of $1,000,000 coverage. E. ☐ materials with the minimum amount of $5,000,000 coverage. F. ☐ The applicant has an approved self-insurance plan or other security in full force and effect and the carrier is in full compliance with the conditions imposed by G. ☐ using only vehicles with seating capacity of fewer than 16 passengers with the minimum amount of $1,500,000 coverage. H. ☐ using vehicles with seating capacity greater than 15 passengers with the minimum amount of $5,000,000 coverage. 31. and $10.00 per vehicle fee. Number of Vehicles Per Vehicle Fee $10.00 Total Fee Due $ (Take the number of vehicles and times it by the $10 per vehicle fee to obtain the total amout of fees due) Check One: ☐ Original Fee Calculation ☐ Supplemental Fee Calculation NOTE: No fees are due if you are an intrastate private carrier of non-hazardous materials. 32. I certify that I am familiar with the Federal Motor Carrier Safety Regulations and/or the Federal Hazardous Materials Regulations as adopted by Indiana law. Under penalties of perjury, I declare that the information entered on this report is, to the best of my knowledge and belief, true, correct, and complete. _________________________________________________________________________________________________________ Authorized Signature Printed Name Title Date Mail This Form To: Indiana Department of Revenue Motor Carrier Services Division PO Box 6075 Indianapolis, IN 46206-6075 If you need to mail via overnight or express mail, our street address is: 5252 Decatur Blvd., Ste. R Indianapolis, IN 46241-9524 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form BAS-1 Note that lines 1 through 28A of this form were designed to mirror the federal form MCS-150. Section A: Motor Carrier Information Section B: Type of Motor Carrier Operation Line 1: Enter the legal name of the business entity (i.e., corporation, partnership, or LLC, LLP or individual) which owns/controls the motor carrier/shipper operation. All carriers must complete this section for the current year of registration. Complete this section even if you already have a US DOT number. This will ensure that your registration information is as current as possible. Line 2: If your business entity is operating under a name other than that on Line 1, (i.e., “DBA name”) enter that name. Otherwise, leave this line blank. Line 3: Enter your principle place of business street address (where all safety records are maintained). NOTE: A P.O. Box is not acceptable here. Line 4: Enter your mailing address if it is different from the physical address listed on Line 3. If your mailing address is the same as Line 3, leave this area blank. Line 5: Enter the city where your principle place of business is located. Line 6: Enter the two-letter postal abbreviation for the State, or the name of the Canadian Province, in which your principal place of business is located. Line 7: Enter the ZIP code number corresponding with the street address. Line 11: Enter the name of the county in which your principle place of business is located. Line 12: Enter the telephone number, including the area code, of the principal place of business. Line 21: Check the appropriate type of carrier operation. A - Interstate hazardous materials - Transportation of hazardous materials across state lines. (49 CFR 100-180) B - Intrastate hazardous materials - Transportation of hazardous materials wholly within one state. (49 CFR 100-180) C - Intrastate, non-hazardous materials - Transportation of persons or property wholly within one State. D - Interstate non-hazardous materials - Transportation of persons or property across state lines, including international boundaries, or wholly within one state as part of a through movement that originates or terminates in another State or Country. Line 22: Check the appropriate type of shipper operation. Line 23: Enter the carrier’s total mileage to the nearest 10,000 miles for the past calendar year and the year of the mileage. Line 24: apply. all that Line 13: Enter cell phone number, including the area code. A - Authorized for hire: Transportation for compensation as a common or contract carrier of property, owned by others, or passengers under the provisions of the MC/FHWA. Line 17: (FEIN) assigned to your motor carrier operation by the Internal Revenue Service. (Partnerships must have a FEIN Number) B - Exempt for hire: Transportation for compensation of exempt commodities exempt from the economic regulation by the MC/ FHWA. Line 18: Enter your US DOT Number or Indiana ID number assigned to your motor carrier operation by either the U.S. Department of Transportation or the Indiana Department of Revenue. Otherwise enter “N/A”. C - Private (property): A person who provides transportation of property by commercial motor vehicle and is not a for hire motor carrier (hauling your own product in your vehicle). Line 19: Enter the motor carrier “MC” number under which the Federal Highway Administration (FHWA) issued your operating authority, if applicable. Otherwise enter “N/A”. D - Private Passengers (Business): A private motor carrier engaged in the interstate or intrastate transportation of passengers which is provided in the furtherance of a commercial enterprise and is not available to the public at large (e.g. touring bands). Line 20: Enter your Internet E-mail address if you have one. E A private motor carrier involved in the interstate or intrastate transportation of passengers of passengers (e.g., church buses). American LegalNet, Inc. www.FormsWorkFlow.com F - Broker (Intrastate Household Goods & Passengers): A person who, for compensation, arranges or offers to arrange the transportation of household goods and/or passengers by an authorized motor carrier. Motor carriers, or persons who are Section C: Business Type the meaning of this section when they arrange or offer to arrange the transportation shipments which they are authorized to transport and which they have accepted and legally bound themselves to transport. if necessary. Line 25: transport. If “DD Other” is checked, enter the name of the commodity in the space provided. any motor carrier to operate a vehicle in Indiana without the proper Line 26: Circle all types of hazardous material (HM) you carry/ ship. Line 31: If you are an intrastate only for-hire carrier or a private carrier transporting hazardous materials, calculate your fees due by listing your total number of vehicles and multiplying times $10 to determine your total amount due. In the columns before the HM types, either circle C for carrier of HM, or S for a shipper of HM. In the columns following the HM types, either circle B if the HM is transported in bulk (over 119 gallons) or NB if the HM is transported in non-bulk (119 gallons or less). The HM types correspond to the classes and divisions listed in 49 CFR 173.2. Note: Information on Poison Inhalation Hazards is found in column (7) of the hazardous materials table (49 CFR 172.101). Line 27: Enter the total number of vehicles owned, term leased or trip leased, that are, or can be, operational the day this form is completed. Motor Coach: A vehicle designed for long distance transportation Line 29: Tell us what type of business organization you are. NOTE: If you are formed as a partnership or are incorporated, Line 30: Proof of Public Liability Security: Enter your insurance company’s name and your policy number and the effective date. Line 32: This form must be signed by an individual authorized to sign documents on behalf of the entity listed on Line 1. Print or type the name, in the space provided, of the authorized individual signing this return. That individual must sign, date, and show his CFR 385.21 and 385.23). Before you seal the envelope... payment, BAS-2, ICC authority, Form E-Indiana, etc.). and a baggage hold beneath the passenger compartment. School Bus primary and secondary students to and from school, usually built on a medium or large truck chassis. Division (317) 615-7350. Mini-bus- A motor vehicle designed or used to transport 16 or more passengers, including the driver, and typically built on a small truck chassis. A mini-bus has a smaller seating capacity than a motor coach. Mail this return and payment to: Indiana Department of Revenue Motor Carrier Services Division Insurance & Safety Section P.O. Box 6075 Indianapolis, IN 46206-6075 Van - A small motor vehicle designed or used to transport 15 or fewer passengers including the driver. If you need to mail via overnight or express mail our street address is: Limousine - A passenger vehicle usually built on a lengthened automobile chassis. Indiana Department of Revenue Motor Carrier Services Division Insurance & Safety Section 5252 Decatur Blvd., Ste. R Indianapolis, IN 46241-9524 Line 28A: Enter the number of interstate/intrastate drivers used on an average work day. Part-time, casual, term leased, trip leased and company drivers are to be included. Also, enter the total number of drivers, and the total number of those drivers who have a Commercial Drivers License (CDL). American LegalNet, Inc. www.FormsWorkFlow.com For Additional Information or Assistance: Interstate/Intrastate Motor Carrier Service Fax Numbers IRP (317) 615-7340 .............................................................................................(317) 821-2335 IFTA/MCFT (317) 615-7345 ................................................................................(317) 821-2335 USDOT/SSRS (317) 615-7350 ..........................................................................(317) 821-2339 Indiana Operating Athority (317) 615-7350 .......................................................(317) 821-2339 Superload Permits (317) 615-7320 .....................................................................(317) 821-2336 Commercial Driver’s License (317) 615-7335 .....................................................(317) 821-2340 Oversize/Overweight Vehicle Permitting (317) 615-7320 .................................(317) 821-2336 Indiana Department of Revenue Motor Carrier Services Division 5252 Decatur Blvd., Suite R Indianapolis, IN 46241 (317) 615-7200 TaxFax: (317) 233-2329 Web site Address: www.in.gov/dor/ Indiana State Police Commercial Vehicle Enforcement Division 5252 Decatur Blvd., Suite J Indianapolis, IN 46241 (317) 615-7373 1-800-523-2226 Fax: (317) 821-2350 Web site: www.in.gov/isp/ (Federal Dept. of Transporation) 575 N. Pennsylvania, Suite 261 Indianapolis, IN 46204 (317) 226-7474 Fax: (317) 226-5006 Web site: www.safersys.org/ http://li-public.fmcsa.dot.gov/ American LegalNet, Inc. www.FormsWorkFlow.com