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YOUR TRANSACTION IS NOW SECURE
DOT COMPLANCE HELP, INC.
Distracted Driving Policy Order Form
Please complete the short form below. After we have received all of your information, we will build your customized policy statement. Feel free to contact us to discuss any other modifications you need. Please allow 5-10 business days for completion. Call us if you need to expedite your order.
Part A - Company Information
Company Name
*
US DOT #
*
Company Phone
*
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Point of Contact
*
Title
*
Email Address
*
Part B - Company Preferences
CMVs vs ALL Vehicles:
Would you like your policy to cover just DOT-regulated vehicles (CMVs) OR also include other company vehicles such as sales cars and trucks?
*
ALL Company Vehicles (Recommended)
Commercial Motor Vehicles only
HAND-HELD vs. HANDS-FREE Devices:
The DOT has banned the use of HAND-HELD cell-phones while operating a commercial motor vehicle, however, certain ‘HANDS-FREE’ devices (such as bluetooth headsets) are currently still allowed. Would you like your policy to restrict ALL cell-phone usage or just HAND-HELD but allow HANDS-FREE devices?
*
Restrict ALL cell-phone usage (Recommended)
Allow use of HANDS-FREE devices
How many warnings for violating this policy will you allow before termination?
*
One
Two
Three
Four
Five
Other
Other
SAFETY BONUS:
This can be anything but one example might be:
For each
QUARTER
that no one gets a ticket for driving and talking on a phone, we are going to give each driver a
$100 BONUS
. But, if
ANYONE
gets caught talking on a phone,
NOBODY
gets the bonus.
Would you like to include a safety bonus of some sort for your drivers?
*
No
Yes (please explain bonus structure below)
Provide any other specific guidelines, statements or comments that you would like included in your policy.
Payment Information
NOTE: The amount billed will be
$199
.
Type in Coupon Code if applicable:
How would you like to pay? (enter payment information below)
Choose one...
Credit Card
Electronic Check
Credit Card Information
Credit Card Type
Choose one...
Visa
MasterCard
American Express
Discover
Name on Card
Credit Card Number
Expiration Date
CVC Code
🛈
Street address/PO Box and Zip Code where BILLED
Electronic Check Information
Account Type
Choose one...
Business
Personal
Name as it Appears on the Account
Routing Number
🛈
Account Number
🛈