Towing Contract With Allstate PDF Details

If you'd like to first determine how much time you need to fill out the towing contract with allstate and how many pages it has, here is some detailed data that may be of use.

Form NameTowing Contract With Allstate
Form Length13 pages
Fillable fields0
Avg. time to fill out3 min 15 sec
Other nameshow to tow for insurance companies, allstate towing contract, allstate service provider application, how to get towing accounts

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Servicer Application Checklist

Your application will not be processed unless all of the below items

have been completed and returned in 7 days.

(Please check enclosed items.)

6Completed copy of the Independent Servicer Provider Agreement signed and dated on last page.

6Completed copy of the “Provider Application.”

6Completed copy of the Background Authorization Form signed and dated.

6Enclose copy of current Certiicates of Insurance issued to Allstate Roadside Services, which comply with the limits set forth in Section 9 of the Allstate Roadside Services Independent Service

Provider Agreement. Do not send separately.

6Complete enclosed zip codes for the areas you can cover & list the zip codes in numerical order.

6Complete enclosed W-9 Form (rev. 12/11).

6Copy of Owner’s Drivers License.

6Email the contract to

If you’re mailing the contract, mail to: Allstate Roadside Services Auto Network Support

P.O. Box 4433

Carol Stream, IL 60197-4433

Once we receive your completed application, an Allstate Roadside Services Network Consultant will contact you to discuss your customized rate schedule. We have enclosed a blank rate schedule for your review.



Independent Service Provider Agreement ISP Number_____________________

This Agreement made this________day of______________________, 20________, by and between Allstate Motor Club,

Inc., Signature Motor Club, Inc., Signature Motor Club of California, Inc., Mobil Auto Club, Inc., Signature’s

Nationwide Auto Club, Inc., Signature’s Nationwide Auto Club of California, Inc., and Ocoma Industries, Inc. with ofices at 2775 Sanders Road, Suite E2, Northbrook, Illinois 60062-6127 hereinafter called “ARS,” and


(Corporate or Legal Name)


with a place of business at(Street Address)




and doing business as

(DBA/Known As)

who is an Independent Service Provider (hereinafter called “ISP”).


WHEREAS, ARS offers auto plans and various towing and automobile assistance dispatch services to members of the general public who enroll in or are otherwise eligible for ARS’s programs (“Members”); and

WHEREAS, ISP wishes to provide services such as towing and fuel delivery (hereinafter “Services”), as indicated on the ISP’s Provider Application attached and incorporated herein, to Members of ARS;

NOW THEREFORE, in consideration of the mutual promises and consideration contained herein, the suficiency of which each party acknowledges, the parties to this Agreement agree as follows:

1.Dispatch. ARS shall contact and dispatch ISP to perform service calls for Members with disabled vehicles who are in need of Services. Upon receipt of a dispatch call from ARS, ISP shall furnish ARS with an estimated time of arrival (“ETA”) to the location of the Member in need of Services. ISP agrees that it shall use its best efforts to arrive at the Member location within the given ETA. If there are any changes to the ETA, the ISP is required to update ARS with the change. ISP shall be available to accept ARS dispatches during its hours of operation as listed on the Provider Application and shall inform ARS of any changes in its hours of operation.

2.Provision of Services. ISP shall be solely responsible for the provision of Services to Members. ISP shall provide

the Services in a safe and professional manner and shall be solely responsible for determining the proper equipment and methods for providing the Services. Drivers must be uniformed and must maintain a clean and neat appearance. Trucks must be maintained in a clean, safe and properly equipped manner displaying your company name. ISP shall be solely responsible for maintaining its own equipment as listed on its Provider Application and shall inform ARS of any changes in the equipment ISP has available for ARS work. ISP shall be solely responsible for any personal injury or property damage resulting from the ISP’s failure to perform the Services in a safe and professional manner.

3.Rate Schedule. ISP will charge ARS for Services rendered to Members as stated in the Rate Schedule which is incorporated herein by reference and as it may be amended from time to time. ISP agrees that it will not charge ARS or Members any fee in excess of the Rate Schedule or any amendments thereto, and that ARS may chargeback to ISP and deduct from any monies due ISP, any fee or charge in excess of the Rate Schedule.

ISP acknowledges that ARS’s programs contain restrictions and limitations on the use of Services by Members. On some occasions, Members may require Services in excess of those covered by ARS, including, but not limited to, towing vehicles distances beyond the mileage limitations set by ARS. In such instances, ISP agrees it shall charge the Member directly at the rates set forth in the Rate Schedule for any and all charges not covered by ARS. ISP agrees that it shall be solely responsible for collecting any fees from Members that are not covered by ARS, and that ARS shall not have any obligation to pay for such non-covered Services or attempt to collect payment for such non-covered Services from Members on the ISP’s behalf.

In the event that a member of the general public contacts the ISP seeking services, ISP agrees that it will inquire if such ISP customer is a Member of an ARS Motor Club. If the customer discloses that he or she is a Member of ARS, ISP will disclose its afiliation with ARS. ISP agrees that it will contact ARS to receive authorization to provide Services to such Member and will bill ARS and, if applicable, the Member for Services in accordance with the Rate Schedule. ISP agrees that in the event that ISP provides a Service to a Member of ARS and Member seeks reimbursement from ARS for the Services provided, ARS may charge back and deduct from monies due ISP any amount charged the Member in excess of the rates set forth in the Rate Schedule.


ARS reserves the right to amend the Rate Schedule at any time, and such amended Rate Schedule shall automatically become part of this Agreement unless ISP provides ARS with written notice that ISP is electing to terminate this Agreement in accordance with Paragraph 12.

4.Reimbursement Policy. ARS will reimburse ISP in accordance with the Rate Schedule for Services provided to Members that have been preauthorized by ARS. ISP shall invoice ARS for all such Services rendered at least monthly. The format and information contained in such invoice shall comply with ARS’s standards. ARS reserves the right to deduct from any payment to ISP, any and all monies ISP owes ARS. ARS shall not be obligated to pay ISP for any invoices submitted by ISP in excess of sixty (60) days after the date Service was provided. ARS also shall not be obligated to pay any invoice for Services that were not preauthorized by ARS, or in excess of the rates set forth in the Rate Schedule, or for Services not covered by ARS. ARS shall not be obligated to pay for any parts, permanent repairs or merchandise, or other matter that is not covered as set forth in the applicable ARS membership manual. ISP authorizes ARS to charge back and deduct from any monies owed ISP, all such non-covered charges.

In certain instances, in accordance with ARS’s auto plan beneits, ARS may guarantee payment on a check written by a Member for vehicle repairs or other services not covered by ARS. In such event, ISP shall require the Member to present an unexpired driver’s license and ARS membership card and ISP shall immediately contact ARS for conirmation and approval of the check guarantee request. Upon the issuance of ARS’s guarantee, if such Member check is later returned for insuficient funds, Motor Plan shall reimburse ISP for the amount of the check up to the guaranteed limit and any associated bank charges not to exceed $40. ARS shall not be obligated to pay for any returned check if (a) the check guaranteed was not preauthorized by ARS (b) the check was in an amount in excess of the preauthorized guarantee, or (c) the dishonored check is sent to ARS by ISP for reimbursement more than sixty (60) days after the Services are rendered. Except as speciically provided herein, ARS shall have no obligation to guarantee payment for any repairs or non-covered services provided to Members by ISP.

5.Damage. In the event that a Member alleges that ISP damaged a Member’s vehicle in the course of providing Services, or a Member otherwise alleges any damages as the result of ISP’s actions or omissions, ARS may withhold any monies due ISP for Services under this Agreement pending resolution of the dispute with the Member. If ISP fails to reach a resolution with such Member and ARS in its reasonable discretion believes that the Member's complaint is valid, ARS may reimburse Member and deduct such reimbursement from any monies due ISP.

6.Non-Exclusive. It is expressly understood that this Agreement is not exclusive in any respect. ARS maintains the right to contract with other service providers, including service providers who provide Services within the same geographic area as ISP. Likewise, ISP may contract with other motoring plans to provide services. It is further understood that this Agreement does not guarantee ISP any amount of business, revenue or proit, and ARS is not obligated to refer any amount of business to ISP. ISP expressly waives any claim for lost proits under this Agreement.

7.Trademarks. ISP must obtain prior written consent from ARS for all advertising, displays or promotions using ARS’s names, symbols or other intellectual property, including any advertising in the Yellow Pages or other local telephone directories. Except as otherwise agreed in writing, all approved advertising utilizing ARS’s name, symbols, and other intellectual property shall be done solely at ISP’s expense. ISP may display at its place of business and on its service equipment decals, signs and other materials provided by ARS. Upon termination of this Agreement, ISP agrees that it will immediately cease using ARS’s names, symbols and other intellectual property and will remove all such items at ISP’s sole expense from its advertising, place of business and service equipment.

8.Indemnity. ISP agrees to indemnify and save ARS, its parents, assigns, subsidiaries, afiliates, agents and employees, harmless from and against any and all losses, claims, demands, liabilities, suits or actions, of any kind (including expenses and attorneys’ fees) for injuries to or death of any person or persons, including the employees of each party hereto, and property loss or damage connected with the performance of this Agreement, whether or not caused by

a negligent act or omission of either party hereto, its agents, contractors or employees, except that ISP assumes no liability for the sole negligent acts of ARS. The ISP agrees that the offset of monies in response to a Member’s damage complaint does not alter or in any way lessen the ISP’s obligations under this paragraph except as to matters which are fully resolved by such offset. This paragraph shall survive the termination or expiration of this Agreement.

9.Insurance. During the term of this Agreement, ISP will maintain at its own expense:

(a)Worker’s Compensation and Occupational Diseases insurance as required by any applicable law.

(b)Comprehensive General and Automobile Liability insurance, including Contractual Liability insurance speciically insuring ISP against the liabilities assumed under the Indemnities Paragraph with minimum limits of $100,000 each person and $300,000 each occurrence for bodily injury and $100,000 each occurrence for property damage or a minimum combined single limit for bodily injury and property damage of $300,000 per occurrence;

(c)Garage Keepers’ Legal Liability or Garage Keeper’s Liability insurance (including, but limited to “On-Hook” Liability insurance) with a minimum limit of $25,000; and,

(d)Any additional coverage or limits as may be required by applicable law. ISP will have a Certiicate of Insurance issued to Motor Club evidencing ISP’s compliance with these insurance requirements. It is the responsibility of ISP to keep such insurance certiicates current. ISP understands that it will not be used for Services if Motor Club does not have a current Certiicate of Insurance on ile.


ISP speciically authorizes ARS to provide, upon request, any and all information it may have regarding ISP’s insurance coverage, including but not limited to copies of insurance certiicates and declarations pages, to a Member, an attorney representing a Member, or any governmental agency. ARS shall have no obligation to validate any such request, however it shall use reasonable best efforts to inform ISP upon the receipt of any such request. ISP agrees that any such information shall not be considered proprietary or conidential.

The purchase of such insurance will not be in satisfaction of the ISP’s obligations under paragraph 8 Indemnity. Any deductibles or liability beyond the policy limits are the responsibility of ISP. ISP will not delay or refuse to satisfy any claim arising out of the services performed under this Agreement because of a deductible or policy limit. In the event that ISP and ISP’s insurer do not fully pay for any damage claim, ARS may reimburse Member and offset such amount from any

amounts due ISP.

10.Technology. By signing this agreement you hereby agree to the terms of use and privacy statements for technologies provided by ARS to you that are currently in use or will be used in the future and agree to read and abide by them as they are displayed within each application.

11.Conidentiality. ISP agrees that any information about ARS’s Members represents the conidential information of the Member, and (as between the ISP and ARS) ARS. ISP agrees that it will not sell, copy or transfer any information about a Member to any third party without ARS’s express written approval and that it shall not, without the express permission of the Member, use information acquired in the provision of services pursuant to this Agreement for any purpose whatsoever except as necessary to perform such services and to bill and collect payment if services are billed directly to the Member by the ISP. ISP agrees that the terms and conditions of this Agreement including the Rate Schedule represent ARS’s conidential information and ISP shall not divulge the contents of this Agreement to any third party without ARS’s express written approval or except as required by law. ISP agrees that it shall maintain data security processes and procedures to reasonably ensure the security of Member personal and inancial information. Such processes and procedures shall, at minimum, satisfy all applicable laws and industry standards applicable to ISP. This paragraph shall survive the termination or expiration of this Agreement.

12.Termination. This Agreement may be terminated at will and without cause.

13.Independent Contractor. For the purpose of this Agreement, ISP is acknowledged by both parties to be an independent contractor. ISP independently manages his/her own business and is neither an employee or an agent of ARS. ISP has no authority to transact any business whatsoever in ARS’s name.

14.Change in Ownership. Change in ownership results in the termination of this agreement and new owner will have to ile for a new agreement with ARS.

15.Notices. All notices will be sent to the ISP contact information on ile with ARS. it is the ISP’s responsibility to keep this information current.

16.Compliance with Law. ISP and ARS will comply with federal, state and local laws and regulations regarding their obligations under this Agreement. ISP will provide copies of all licenses, permits, etc., required to conduct business as an Emergency Road or Tow operator upon request by ARS.

17.Entire Agreement. This Agreement comprises the entire agreement between the parties. All modiications and amendments, with the exception of the Rate Schedule, must be in writing and executed by the parties. The Rate Schedule may be amended inilaterally by ARS and shall be binding upon the ISP once accepted. ISP shall be deemed to have accepted ARS’ revised Rate Schedule by performing services following receipt of a revised Rate Schedule.

18.Governing Law. The validity, interpretation, and construction of this Agreement will be governed by the laws of the State of Illinois without regard to its conlict of laws provisions. ISP agrees and consents that the exclusive jurisdiction and venue for any dispute between the parties to this Agreement shall be limited to a local, state or federal court situated within the city of Chicago and/or Cook County, Illinois.

19.Assignment. ISP will not assign or subcontract this Agreement without ARS’s prior consent.

20.Counterparts. This Agreement may be executed in any number of counterparts, each of which is deemed an original and all of which together constitute one and the same instrument. ARS may accept an executed Agreement returned by facsimile as an original executed Agreement and such executed facsimile shall be binding upon ISP. ARS may accept an electronic acknowledgement or signature of this Agreement as an original executed Agreement and such electronic acknowledgement or signature shall be binding upon ISP.

21.Drug Screening and Criminal or Abusive Behavior. ISP shall not permit any employee or contractor to perform or assist in providing roadside services, towing of any vehicle or otherwise have contact with a Member or other individual pursuant to this agreement if:

(1)The employee has not consented to and passed a drug screening procedure conducted by a reputable, licensed provider at least once every 12 months. This requirement will be waived if the ISP provides proof that such testing violates applicable law in the state or locality where services are provided; or


(2)The employee has been convicted of any crime bearing upon the individual’s itness to have responsibility for the tasks being assigned to the individual or for which the ISP’s owner(s) or manager(s) know or should reasonably know, any other information, including but not limited to evidence of current violent or physically abusive behavior, indicating that the individual poses a signiicant risk to the health or safety of others that cannot be eliminated by reasonable accommodations.

By signing the below you consent that you may need to provide personal information to ARS in order to complete the application process.

IN WITNESS WHEREOF, the parties have caused this Agreement to be executed as of the date irst written above

Independent Service Provider







For ofice use only

Allstate Roadside Services








Form W-9



Request for Taxpayer



Give Form to the

(Rev. December 2011)


Identification Number and Certification

requester. Do not




Department of the Treasury


send to the IRS.







Internal Revenue Service



















Name (as shown on your income tax return)














page 2.

Business name/disregarded entity name, if different from above















Check appropriate box for federal tax classification:














Individual/sole proprietor

C Corporation

S Corporation





typeorPrint InstructionsSpecific



Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)


Exempt payee







Other (see instructions)
















Address (number, street, and apt. or suite no.)




Requester’s name and address (optional)











City, state, and ZIP code



























List account number(s) here (optional)


















Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Social security number







Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3.I am a U.S. citizen or other U.S. person (defined below).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.


Signature of




U.S. person



General Instructions

Note. If a requester gives you a form other than Form W-9 to request

Section references are to the Internal Revenue Code unless otherwise

your TIN, you must use the requester’s form if it is substantially similar

to this Form W-9.






Definition of a U.S. person. For federal tax purposes, you are



Purpose of Form

considered a U.S. person if you are:


A person who is required to file an information return with the IRS must

• An individual who is a U.S. citizen or U.S. resident alien,



obtain your correct taxpayer identification number (TIN) to report, for

• A partnership, corporation, company, or association created or

example, income paid to you, real estate transactions, mortgage interest

organized in the United States or under the laws of the United States,

you paid, acquisition or abandonment of secured property, cancellation

• An estate (other than a foreign estate), or


of debt, or contributions you made to an IRA.


• A domestic trust (as defined in Regulations section 301.7701-7).

Use Form W-9 only if you are a U.S. person (including a resident

Special rules for partnerships. Partnerships that conduct a trade or

alien), to provide your correct TIN to the person requesting it (the

business in the United States are generally required to pay a withholding

requester) and, when applicable, to:

tax on any foreign partners’ share of income from such business.

1. Certify that the TIN you are giving is correct (or you are waiting for a

Further, in certain cases where a Form W-9 has not been received, a

number to be issued),

partnership is required to presume that a partner is a foreign person,



2. Certify that you are not subject to backup withholding, or

and pay the withholding tax. Therefore, if you are a U.S. person that is a

3. Claim exemption from backup withholding if you are a U.S. exempt

partner in a partnership conducting a trade or business in the United

States, provide Form W-9 to the partnership to establish your U.S.

payee. If applicable, you are also certifying that as a U.S. person, your

status and avoid withholding on your share of partnership income.

allocable share of any partnership income from a U.S. trade or business



is not subject to the withholding tax on foreign partners’ share of



effectively connected income.




Cat. No. 10231X

Form W-9 (Rev. 12-2011)


Form W-9 (Rev. 12-2011)

Page 2



The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases:

The U.S. owner of a disregarded entity and not the entity,

The U.S. grantor or other owner of a grantor trust and not the trust, and

The U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person, do not use Form W-9. Instead, use the appropriate Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1.The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2.The treaty article addressing the income.

3.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4.The type and amount of income that qualifies for the exemption from tax.

5.Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8.

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1.You do not furnish your TIN to the requester,

2.You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3.The IRS tells the requester that you furnished an incorrect TIN,

4.The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5.You do not certify to the requester that you are not subject to

backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W-9.

Also see Special rules for partnerships on page 1.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies.


Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions


If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form.

Sole proprietor. Enter your individual name as shown on your income tax return on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name/disregarded entity name” line.

Partnership, C Corporation, or S Corporation. Enter the entity's name on the “Name” line and any business, trade, or “doing business as (DBA) name” on the “Business name/disregarded entity name” line.

Disregarded entity. Enter the owner's name on the “Name” line. The name of the entity entered on the “Name” line should never be a disregarded entity. The name on the “Name” line must be the name shown on the income tax return on which the income will be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a domestic owner, the domestic owner's name is required to be provided on the “Name” line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the “Business name/disregarded entity name” line. If the owner of the disregarded entity is a foreign person, you must complete an appropriate Form W-8.

Note. Check the appropriate box for the federal tax classification of the person whose name is entered on the “Name” line (Individual/sole proprietor, Partnership, C Corporation, S Corporation, Trust/estate).

Limited Liability Company (LLC). If the person identified on the “Name” line is an LLC, check the “Limited liability company” box only and enter the appropriate code for the tax classification in the space provided. If you are an LLC that is treated as a partnership for federal tax purposes, enter “P” for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for C corporation or “S” for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301.7701-3 (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the “Name” line) is another LLC that is not disregarded for federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner identified on the “Name” line.


Form W-9 (Rev. 12-2011)

Page 3



Other entities. Enter your business name as shown on required federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name/ disregarded entity name” line.

Exempt Payee

If you are exempt from backup withholding, enter your name as described above and check the appropriate box for your status, then check the “Exempt payee” box in the line following the “Business name/ disregarded entity name,” sign and date the form.

Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends.

Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.

The following payees are exempt from backup withholding:

1.An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2),

2.The United States or any of its agencies or instrumentalities,

3.A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities,

4.A foreign government or any of its political subdivisions, agencies, or instrumentalities, or

5.An international organization or any of its agencies or instrumentalities.

Other payees that may be exempt from backup withholding include:

6.A corporation,

7.A foreign central bank of issue,

8.A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States,

9.A futures commission merchant registered with the Commodity Futures Trading Commission,

10.A real estate investment trust,

11.An entity registered at all times during the tax year under the Investment Company Act of 1940,

12.A common trust fund operated by a bank under section 584(a),

13.A financial institution,

14.A middleman known in the investment community as a nominee or custodian, or

15.A trust exempt from tax under section 664 or described in section


The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 15.

IF the payment is for . . .

THEN the payment is exempt


for . . .



Interest and dividend payments

All exempt payees except


for 9



Broker transactions

Exempt payees 1 through 5 and 7


through 13. Also, C corporations.



Barter exchange transactions and

Exempt payees 1 through 5

patronage dividends




Payments over $600 required to be

Generally, exempt payees

reported and direct sales over

1 through 7 2

$5,000 1




1See Form 1099-MISC, Miscellaneous Income, and its instructions.

2However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at You may also get this form by calling

1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8.

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, below, and items 4 and 5 on page 4 indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on the “Name” line must sign. Exempt payees, see Exempt Payee on page 3.

Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4.

1.Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2.Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3.Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.


Form W-9 (Rev. 12-2011)

Page 4



4.Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5.Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Requester


For this type of account:

Give name and SSN of:







The individual



Two or more individuals (joint

The actual owner of the account or,



if combined funds, the first



individual on the account 1


Custodian account of a minor

The minor 2



(Uniform Gift to Minors Act)



4. a. The usual revocable savings

The grantor-trustee 1


trust (grantor is also trustee)




b. So-called trust account that is

The actual owner



not a legal or valid trust under






state law




Sole proprietorship or disregarded

The owner 3



entity owned by an individual




Grantor trust filing under Optional

The grantor*



Form 1099 Filing Method 1 (see




Regulation section 1.671-4(b)(2)(i)(A))







For this type of account:

Give name and EIN of:






Disregarded entity not owned by an

The owner







A valid trust, estate, or pension trust

Legal entity 4



Corporation or LLC electing

The corporation



corporate status on Form 8832 or




Form 2553




Association, club, religious,

The organization



charitable, educational, or other




tax-exempt organization




Partnership or multi-member LLC

The partnership



A broker or registered nominee

The broker or nominee


Account with the Department of

The public entity



Agriculture in the name of a public




entity (such as a state or local




government, school district, or




prison) that receives agricultural




program payments




Grantor trust filing under the Form

The trust



1041 Filing Method or the Optional




Form 1099 Filing Method 2 (see




Regulation section 1.671-4(b)(2)(i)(B))







1List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2Circle the minor’s name and furnish the minor’s SSN.

3You must show your individual name and you may also enter your business or “DBA” name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1.

*Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

Protect your SSN,

Ensure your employer is protecting your SSN, and

Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: or contact them at or 1-877-IDTHEFT (1-877-438-4338).

Visit to learn more about identity theft and how to reduce your risk.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.


2775 Sanders Road, Suite E2

Northbrook, IL 60062-6127

Business Information

ISP Number______________________

Business Name:

Owner’s Name:

Physical Equipment Location (no P.O. Boxes):







































ZIP Code

Mailing Address (if different):






































ZIP Code

Email address































Phone Numbers












) _____________________________

Alternate Dispatch





) _____________________________

Alternate Ofice





) _____________________________

Alternate Fax



Business or station hours:

Owner’s Phone Number


) __________________

24 hours: 2 Yes 2 No

Owner’s Cell Phone Number (

) __________________

Monday–Friday ________________________________






Saturday _____________________________________






Sunday ______________________________________






Your Federal Tax ID Number

Social Security Number

Number of years n business















Insurance Information for your commercial vehicles


Insurance Company

Agent’s Name







Agency Phone Number

Policy Number(s)







Allstate Motor Club, Inc. and Allstate Enterprises, LLC must be named as certiicate holders. Current Insurance Information

should be attached for the application to be processed. W9 form to be completed and attached to the application.


Service Data



Do your drivers use smart phones?

Do you use digital dispatch?

Are you interested in digital dispatch?

2 Yes 2 No

2 Yes 2 No What provider? _________

2 Yes 2 No

Service Available



Please check all that apply:


6 Dollies


Fuel Delivery

6 Flatbed


Jump start





6 Winch


Locksmith on site


Tire Change


Do you provide service for other motoring clubs; i.e., secondary or transporting? Do you tow:


2 Yes

2 No








6 Light Duty

6 Medium Duty 6 Heavy Duty

Specify: You tow for












6 Agero

6 Geico


6 Others (please list): _____________________________

What method of payment will you accept from our members?






6 Personal Checks

Credit Cards:

6 American Express

6 Discover

6 MasterCard 6 Visa

Do you have a repair facility?

Do you do: body work?

engine? tire?

electrical work?


2 Yes

2 No



2 Yes

2 No

2 Yes

2 No

2 Yes

2 No

2 Yes

2 No

Repair Hours:

Monday to Friday _______ to _______ Saturday _______ to _______

Sunday _______ to _______

Do you have an impound/storage lot?








2 Yes

2 No













Monday to Friday _______ to _______

Saturday _______ to _______ Sunday _______ to _______









Manned Security





2 Yes


2 No

2 Yes

2 No


2 Yes

2 No



Do you have a storage lot?



Do you handle accidents?





2 Yes

2 No




2 Yes

2 No






Optional Owner Information











2 African American

2 Asian




2 M

2 F




2 Caucasian

2 Hispanic








2 Native American

2 Other __________________





Number of vehicles insured to tow for motoring club. (Insurance Certiicate should relect the number of vehicles speciied below.)





Area of Coverage

Wheel Lift


Heavy Duty Vehicle

Service Vehicle


Equipped to handle motorcycles Equipped to handle RVs Equipped to handle Electric Lockouts Equipped to handle Manual Lockouts Equipped to handle Medium Duty

The service area you will cover is determined by ZIP codes. Please describe your “usual” area of coverage by recording the ZIP codes(s) below: Quick (ETA’s less than 30 minutes)

Other ZIP Codes covered:

Please print any additional ZIP codes of coverage areas on a separate wheet of paper and attach.


Consent to Request Consumer Report & Investigative Consumer Report Information

I understand that Allstate Roadside Services (“COMPANY”) will use AISS, a Sterling Infosystems Company, 5111 Oak Tree Boulevard, Independence, OH 4131, (800) 853-3228, to obtain a consumer report and/or investigative consumer report (“Report”) as part of the contracting process. I also understand that if contracted, to the extent permitted by law, COMPANY may obtain further Reports from AISS so as to update, renew or extend my contract.

I hereby consent to this investigation and authorize COMPANY to procure a Report on my background.

In order to verify my identity for the purposes of Report preparation, I am voluntarily releasing my date of birth, social security number and the other information and fully understand that all employment decisions are based on legitimate

non-discriminatory reasons.

The name, address and telephone number of the consumer reporting agency designated to handle inquiries regarding the investigative consumer report is: AISS, a Sterling Infosystems Company | 6111 Oak Tree Boulevard, Independence, OH 44131 | 800-853-3228 Option 3

Any copy of this authorization shall have the same authority as the original.

6California, Minnesota & Oklahoma Applicants Only: I have the right to request a copy of any Report obtained by COMPANY from AISS by checking the box. (Check only if you wish to receive a copy)

By signing this you consent that you will be responsible for the backgrounds of your employees or agents of your organization.




Today’s Date






First Name


Middle Name or Initial Last Name



















Other Names Known by (and/or Maiden Name)



















































Social Security Number (required)



Date of Birth (MMDDYYYY)


































Current Home Address (No PO Boxes allowed)







Apt #






























































Previous Home Address (No PO Boxes allowed)







Apt #






























#yrs at this address

ZIP Code

#yrs at this address

ZIP Code



Proof of insurance is one of the requirements needed to maintain an active status in our national dispatch network. Allstate Roadside Services requires a valid insurance certiicate be on ile at

all times.

Please instruct your insurance carriers to list Allstate Motor Club, Inc. and Allstate Enterprises, LLC as Certiied Holders on the certiicate. This certiicate of insurance should show the following:

Allstate Roadside Services

Auto Network Support

P.O. Box 4433

Carol Stream, IL 60197-4433

A copy of the certiicate should be either faxed to (866) 253-0022 or mailed to the above address.

The minimum insurance coverage requirements for Allstate Roadside Services service providers are as follows:

A. Worker’s Compensation and Occupational Diseases as required by applicable state laws.

B. Comprehensive General & Automobile Liability Insurance with the minimum limits of $100,000 each person and $300,000 each occurrence for bodily injury and $100,000 for property damage or a minimum combined single limit for bodily injury and property damage of $300,000 per


C. Garage Keeper’s Legal Liability (including, but not limited to, “On-Hook” Liability Insurance) with a minimum limit of $25,000 and any additional coverage for limits, as may be required by applicable laws.

D. Service Provider shall provide Allstate Roadside Services with a Certiicate of Insurance evidencing Service Provider’s compliance with these requirements.

It is imperative that this information be submitted with your application. Failure to do will delay the

processing of your application.

To expedite your application these instructions should be faxed to your insurance provider.


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