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 *

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? *

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)

Credit Card Information