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The Owner of &/or The Driver of Truck#

of (the carrier) a licensed Motor Carrier, MC#,
and/or DOT#
; hereby grants authorization to :Assurance USA;
Branch. to act as my agent for the sole purpose of searching for and booking shipments, processing all
brokerage paperwork and obtaining Certificates of Insurance as required in order to expedite shipments and dispatch via telephone, fax or
e-mail for my truck, Unit#
, License Plate#,
in the state of,

Carrier authorizes Assurance USA Branch to function as its sole representative with 

respect to; billing, invoicing and processing collections of revenue from customers, brokers, shippers, consignees, etc.- Carrier retains sole responsibility for thereof. If revenue for a shipment or shipments is uncollectible, “Assurance USA and its representatives” will be held harmless and no penalty or deduction of fees will be made. The carrier agrees to maintain all proper licenses and permits to conduct business as a motor carrier in the area of intended operation. Additionally, carrier agrees to maintain liability and cargo insurance at the amounts set forth by the home state of the carrier. {Assurance USA & its representatives}. will be held harmless in the event of any & all claims. Assurance USA agrees to maintain accounts with (internet load board services &/or direct shippers), for the purpose of load matching on behalf of the carrier, with {Assurance USA Branches & its representatives}. as the point of contact for dispatching purposes.

The fee for dispatch services will be $1,000.00 Monthly or $250.00 Weekly.


Weekly or Monthly Auto pay will be payable to: {RBBS Assurance USA }. Payments are to be conveniently billed via Auto-pay using any Debit or Credit Card authorized for use by the Carrier. Processed by RBBS Assurance USA’s Merchant Account processing. Credit &/or Debit account information will be securely collected during the validation quality assurance call.

Please provide your SMS Cell Phone Text Number Here;                                                        

& Your Email Here;

Either party has the right to end this agreement without cause at any time with seven (7) days’ notice by written request. Upon cancellation, any unused funds remaining in the deposit account will be refunded to the carrier within two (2) business days without penalty.

By Electronically entering my full legal name below, you acknowledge it serves as your legal & binding signature;  I fully understand the terms of this agreement.



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Assurance USA CEO:
Calvin O  Butler
Calvin O Butler
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