State Form 46918 Form Bas-1 - Indiana Business Authorization and Safety Application for Intrastate Carriers - Indiana

Form State46918 is a Indiana Department of Revenue form also known as the "Form Bas-1 - Indiana Business Authorization And Safety Application For Intrastate Carriers". The latest edition of the form was released in June 7, 2018 and is available for digital filing.

Download an up-to-date Form State46918 in PDF-format down below or look it up on the Indiana Department of Revenue Forms website.

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Form BAS-1
Indiana Department of Revenue
State Form 46918
Indiana Business Authorization
(R7 / 6-18 )
and Safety Application for
For Department Use Only
Intrastate Carriers
Renewal (Due November 30th)
for Calendar Year _______
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 No.
20. Email 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)
22. Shipper of Hazardous Materials operation (Check one)
23. Carrier Mileage (To nearest 10,000 miles for last calendar
A.
Interstate (Includes traveling outside Indiana)
year)
B.
Intrastate (Traveling within Indiana only)
24. Operation Classification (Check all that apply)
A.
Authorized For-Hire (Hauling someone else’s product/passengers in your vehicle)
B.
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)
C.
Private (Property) (Hauling your own product in your vehicle)
D.
Private Passengers (Business) (This would apply to Touring Bands, etc.)
E.
Private Passengers (Non-Profit) (This would apply to Church Buses, etc.)
F.
Broker Intrastate Household Goods & Passenger
25. Cargo Classifications (Please check all that apply)
A.
General Freight
I.
Machinery, Large Objects
Q.
Coal/Coke
Y.
Paper Products
B.
Household Goods
J.
Fresh Produce
R.
Meat
Z.
Utility
C.
Metal, Sheets, Coils, Rolls
K.
Liquids/Gases
S.
Garbage, Refuse, Trash
D.
Motor Vehicles
L.
Intermodal Cont.
T.
U.S. Mail
AA.
Farm Supplies
E.
Driveaway/Towaway
M.
Passengers
U.
Chemicals
BB.
Construction
F.
Logs, Poles, Beams, Lumber
N.
Oilfield Equipment
V.
Commodities Dry Bulk
CC.
Water Well
G.
Building Materials
O.
Livestock
W.
Refrigerated Food
DD.
Other ____________
H.
Mobile Homes
P.
Grain, Feed, Hay
X.
Beverages
Form BAS-1
Indiana Department of Revenue
State Form 46918
Indiana Business Authorization
(R7 / 6-18 )
and Safety Application for
For Department Use Only
Intrastate Carriers
Renewal (Due November 30th)
for Calendar Year _______
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 No.
20. Email 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)
22. Shipper of Hazardous Materials operation (Check one)
23. Carrier Mileage (To nearest 10,000 miles for last calendar
A.
Interstate (Includes traveling outside Indiana)
year)
B.
Intrastate (Traveling within Indiana only)
24. Operation Classification (Check all that apply)
A.
Authorized For-Hire (Hauling someone else’s product/passengers in your vehicle)
B.
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)
C.
Private (Property) (Hauling your own product in your vehicle)
D.
Private Passengers (Business) (This would apply to Touring Bands, etc.)
E.
Private Passengers (Non-Profit) (This would apply to Church Buses, etc.)
F.
Broker Intrastate Household Goods & Passenger
25. Cargo Classifications (Please check all that apply)
A.
General Freight
I.
Machinery, Large Objects
Q.
Coal/Coke
Y.
Paper Products
B.
Household Goods
J.
Fresh Produce
R.
Meat
Z.
Utility
C.
Metal, Sheets, Coils, Rolls
K.
Liquids/Gases
S.
Garbage, Refuse, Trash
D.
Motor Vehicles
L.
Intermodal Cont.
T.
U.S. Mail
AA.
Farm Supplies
E.
Driveaway/Towaway
M.
Passengers
U.
Chemicals
BB.
Construction
F.
Logs, Poles, Beams, Lumber
N.
Oilfield Equipment
V.
Commodities Dry Bulk
CC.
Water Well
G.
Building Materials
O.
Livestock
W.
Refrigerated Food
DD.
Other ____________
H.
Mobile Homes
P.
Grain, Feed, Hay
X.
Beverages
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 S A. Division (Class A)
1.1
B NB (Explosives)
C S U. Division
4.2
B NB (Spontaneously
C S B. Division (Class A & B) 1.2
B NB (Explosives)
Combustible)
C S C. Division (Class B)
1.3
B NB (Explosives)
C S V.
Division
4.3
B NB
(Dangerous)
C S D. Division (Class C)
1.4
B NB (Explosives)
C S W.
Division
5.1
B NB
(Oxidizer)
C S E. Division
1.5
B NB (Blasting Agents D)
C S X.
Division
5.2
B NB
(Organic Peroxide)
C S F. Division
1.6
B NB (Explosives N)
C S Y.
Division
6.2
B NB
(Infectious Substance)
C S G. Division
2.1
B NB (Flammable Gas)
C S Z.
Division
6.1A B NB
(Poison Liquid which
C S H. Division
2.1
B NB (LPG - Liquid
is (PIH) Zone A)
Petroleum Gas)
C S AA. Division
6.1B B NB
(Poison Liquid which
C S I.
Division
2.1
B NB (Methane - Methane
is (PIH) Zone B)
Gas)
C S BB. Division
6.1
B NB
(Poison Liquid with no
C S J. Division
2.2
B NB (Oxygen & Non
inhalation hazard)
Flammable Gas)
C S CC. Division
6.1
B NB
(Solid-Poison Solids)
C S K. Division
2.2A B NB (Anhydrous Ammonia)
C S DD. Class
7
B NB
(Radioactive)
C S L. Division
2.3A B NB (Poison Gas which is
C S EE. HRCQ
B NB
(Highway Route
Poison Inhalation
Controlled Quantity of
Hazard (PIH) Zone A)
Radioactive Material)
C S M. Division
2.3B B NB (Poison Gas which is
C S FF. Class
8
B NB
(Corrosive Liquids)
(PIH) Zone B)
C S GG. Class
8A
B NB
(Corrosive Liquids which
C S N. Division
2.3C B NB (Poison Gas which is
is (PIH) Zone A)
(PIH) Zone C)
C S HH. Class
8B
B NB
(Corrosive Liquids which
C S O. Division
2.3D B NB (Poison Gas which is
is (PIH) Zone B)
(PIH) Zone D)
C S II.
Class
9
B NB
(Miscellaneous)
C S P. Class
3
B NB (Flammable Liquids)
C S JJ.
Elevated Temp Mat
B NB
C S Q. Class
3A
B NB (Flammable Liquids
C S KK. Infectious Waste
B NB
which is (PIH) Zone A)
C S LL. Marine Pollutants
B NB
C S R. Class
3B
B NB (Flammable Liquids
C S MM. Hazardous Sub (RQ)
B NB
which is (PIH) Zone B)
C S NN. Hazardous Waste
B NB
C S S. Combustible Liquid
B NB
C S OO. ORM-D
B NB
C S T. Division
4.1
B NB (Flammable Solid)
27. Equipment
Straight
Truck
Trailers
HazMat
HazMat
Number of Passengers (including the driver)
Trucks
Tractors
Cargo
Cargo
Mini-
Vans
Limousines
Motor
School Buses
Tank
Tank
Coaches
bus
Trucks
Trailers
1-8
9-15
16+
16+
1-8
9-15
1-8
9-15
16+
Owned
Term Leased
Trip Leased
Total CDL Drivers
28A. Driver Information
Interstate
Intrastate
Total 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
26,001 - Over
GVWR 17,001 to 26,000
GVWR 10,001 to 17,000
GVWR Under 10,000
Section C: Business Type
29.
Individual
Partnership (list names, addresses)
Corporation (list names, addresses)
LLC (list names, addresses)
Name:
Name:
Name:
Name:
Address:
Address:
Address:
Address:
30. Proof of Public Liability Security
Intrastate For-Hire carriers and/or a Private Hazardous Materials carriers must file a Form E Indiana
(check one)
insurance filing. Carriers with active FHWA/MC authority do not have to submit the Form E filing.
Policy Number
Effective Date
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
non-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.
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
non-hazardous materials with the minimum amount of $750,000 coverage.
D.
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
hazardous materials with the minimum amount of $1,000,000 coverage.
E.
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
hazardous 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 the order. A copy of the self-insurance order is attached or has previously been filed with the registration state.
G.
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
passengers using only vehicles with seating capacity of fewer than 16 passengers with the minimum amount of $1,500,000 coverage.
H.
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
passengers using vehicles with seating capacity greater than 15 passengers with the minimum amount of $5,000,000 coverage.
I.
The applicant is filing, or causing to be filed, a copy of its proof of public liability security in accordance with IC 8-2.1-22-46 for contract carriers
transporting railroad employees with the minimum amount of $5,000,000 coverage.
31. Certification Statement (To be completed by an authorized official) 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: __________________________________________________
Date: _________________________________________
Printed Name: ________________________________________________________
Title: __________________________________________
Direct your questions to the Indiana Motor Carrier Services Division (317) 615-7350.
Mail This Form To:
Overnight or express mail:
Indiana Department of Revenue
7811 Milhouse Road, Suite M
Motor Carrier Services Division
Indianapolis, IN 46241-9612
P.O. Box 6075
Indianapolis, IN 46206-6075
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
C - Intrastate, non-hazardous materials - Transportation of
persons or property wholly within one State.
Line 1: Enter the legal name of the business entity (i.e.,
corporation, partnership, or LLC, LLP or individual) which owns/
D - Interstate non-hazardous materials - Transportation of
controls the motor carrier/shipper operation.
persons or property across state lines, including international
boundaries, or wholly within one state as part of a through
Line 2: If the business entity is operating under a name other than
movement that originates or terminates in another State or
that on Line 1, (i.e., “DBA name”) enter that name. Otherwise,
Country.
leave this line blank.
Line 22: Check the appropriate type of shipper operation.
Line 3: Enter the principle place of business street address
(where all safety records are maintained). Note: A P.O. Box is not
Line 23: Enter the carrier’s total mileage to the nearest 10,000
acceptable here.
miles for the past calendar year and the year of the mileage.
Line 4: Enter the mailing address if it is different from the physical
Line 24: Check the appropriate classification. Check all that
address listed on Line 3. If the mailing address is the same as
apply.
Line 3, leave this area blank.
A - Authorized for hire: Transportation for compensation as
Line 5: Enter the city where principle place of business is located.
a common or contract carrier of property, owned by others, or
passengers under the provisions of the MC/FHWA.
Line 6: Enter the two-letter postal abbreviation for the State, or
the name of the Canadian Province, in which principal place of
B - Exempt for hire: Transportation for compensation of exempt
business is located.
commodities exempt from the economic regulation by the MC/
FHWA.
Line 7: Enter the ZIP code number corresponding with the street
address.
C - Private (property): A person who provides transportation of
property by commercial motor vehicle and is not a for hire motor
Line 11: Enter the name of the county in which your principle
carrier (hauling your own product in your vehicle).
place of business is located.
D - Private Passengers (Business): A private motor carrier
Line 12: Enter the telephone number, including the area code, of
engaged in the interstate or intrastate transportation of
the principal place of business.
passengers which is provided in the furtherance of a commercial
enterprise and is not available to the public at large (e.g. touring
Line 13: Enter cell phone number, including the area code.
bands).
Line 17: Enter Federal Employer Identification Number (FEIN)
E - Private Passengers (Non-Profit): A private motor carrier
assigned to your motor carrier operation by the Internal Revenue
involved in the interstate or intrastate transportation of passengers
Service. (Partnerships must have a FEIN Number)
that does not otherwise meet the definition of a private motor
carrier of passengers (e.g., church buses).
Line 18: Enter US DOT Number or Indiana ID number.
F - Broker (Intrastate Household Goods & Passengers): A
Line 19: Enter the motor carrier “MC” number under which
person who, for compensation, arranges or offers to arrange
the Federal Highway Administration (FHWA) issued operating
the transportation of household goods and/or passengers by
authority, if applicable. Otherwise enter “N/A”.
an authorized motor carrier. Motor carriers, or persons who
are employees or bona fide agents of a carrier, are not brokers
Line 20: Enter Email address.
within the meaning of this section when they arrange or offer to
arrange the transportation shipments which they are authorized
Section B: Type of Motor Carrier Operation
to transport and which they have accepted and legally bound
themselves to transport.
All carriers must complete this section for the current year of
registration. Complete this section even if you already have a US
Line 25: Check all types of cargo classifications that you usually
DOT number. This will ensure that your registration information is
transport. If “DD Other” is checked, enter the name of the
as current as possible.
commodity in the space provided.
Line 21: Check the appropriate type of carrier operation.
Line 26: Circle all types of hazardous material (HM) you carry/
ship.
A - Interstate hazardous materials - Transportation of
hazardous materials across state lines. (49 CFR 100-180)
In the columns before the HM types, either circle C for carrier of
HM, or S for a shipper of HM.
B - Intrastate hazardous materials - Transportation of hazardous
materials wholly within one state. (49 CFR 100-180)
In the columns following the HM types, either circle B if the
Before you seal the envelope...
HM is transported in bulk (over 119 gallons) or NB if the HM
• Do not forget to sign the forms!
is transported in non-bulk (119 gallons or less). The HM types
correspond to the classes and divisions listed in 49 CFR 173.2.
Direct your questions to the Indiana Motor Carrier Services
Division (317) 615-7350.
Note: Information on Poison Inhalation Hazards is found in
Mail this return and payment to:
column (7) of the hazardous materials table (49 CFR 172.101).
Indiana Department of Revenue
Motor Carrier Services Division
Line 27: Enter the total number of vehicles owned, term leased
Insurance & Safety Section
or trip leased, that are, or can be, operational the day this form is
P.O. Box 6075
completed.
Indianapolis, IN 46206-6075
Motor Coach: A vehicle designed for long distance transportation
Overnight or express mail:
of passengers, usually equipped with storage racks above the
Indiana Department of Revenue
seats and a baggage hold beneath the passenger compartment.
Motor Carrier Services Division
Insurance & Safety Section
School Bus: A vehicle designed and/or equipped mainly to carry
7811 Milhouse Road, Suite M
primary and secondary students to and from school, usually built
Indianapolis, IN 46241-9612
on a medium or large truck chassis.
For Additional Information or Assistance:
Mini-bus: A motor vehicle designed or used to transport 16 or
more passengers, including the driver, and typically built on a
Interstate/Intrastate
small truck chassis. A mini-bus has a smaller seating capacity
Motor Carrier Service
Fax Numbers
than a motor coach.
IRP (317) 615-7340 ............................................. (317) 615-7280
IFTA/MCFT (317) 615-7345 ............................... (317) 615-7333
Van: A small motor vehicle designed or used to transport 15 or
USDOT/UCR (317) 615-7350 ........................... (317) 615-7374
fewer passengers including the driver.
Indiana Operating Athority (317) 615-7350 ......... (317) 615-7374
Oversize/Overweight
Limousine: A passenger vehicle usually built on a lengthened
Vehicle Permitting (317) 615-7320 ................... (317) 615-7241
automobile chassis.
Indiana Department of Revenue
Line 28A: Enter the number of interstate/intrastate drivers used
Motor Carrier Services Division
on an average work day. Part-time, casual, term leased, trip
7811 Milhouse Road, Suite M
leased and company drivers are to be included. Also, enter the
Indianapolis, IN 46241-9612
total number of drivers, and the total number of those drivers who
(317) 615-7350
have a Commercial Drivers License (CDL).
Website:
www.in.gov/dor
Email:
IndianaSafety@dor.in.gov
Section C: Business Type
Indiana State Police
Line 29: Type of business organization. Note: Partnerships
Commercial Vehicle Enforcement Division
and Corporations, list your partners or corporate officers. Attach
7811 Milhouse Road, Suite S
additional sheets if necessary.
Indianapolis, IN 46241-9612
(317) 615-7373
Line 30: Proof of Public Liability Security: Enter insurance
1-800-523-2226
company’s name and policy number and the effective date.
Fax: (317) 237-2114
Check the box that reflects required insurance status. It is illegal
Website:
www.in.gov/isp/
for any motor carrier to operate a vehicle in Indiana without the
proper insurance. If this is a renewal application no insurance
Federal Office of Motor Carriers
filing is required.
(Federal Dept. of Transportation)
575 N. Pennsylvania, Suite 261
Line 31: This form must be signed by an individual authorized to
Indianapolis, IN 46204
sign documents on behalf of the entity listed on Line 1. Print or
(317) 226-5657
type the name, in the space provided, of the authorized individual
Fax: (317) 226-5006
signing this return. That individual must sign, date, and show his
Website:
www.safer.fmcsa.dot.gov
or her title in the spaces provided. (Certification Statement, see 49
www.fmcsa.dot.gov
CFR 385.21 and 385.23).
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