LOAD CONFIRMATION & RATE DATE: LOAD #: AMOUNT:
AGREEMENT
Company:
BELLZONE FREIGHT LOGISTICS LLC MC#12345-B Point of Contact
_____________________________ 123-456-7890 Office
_________________ 123-456-7890 Fax
123-456-7890 Cell phone
Shipper:
Carrier Name Driver Name:
______________________________________________ MC#________ ____________ Cell:__________
Address: Phone:
______________________________________________ ____________
Fax:
______________________________________________ ____________
______________________________________________
Special Instructions:
• Charges may apply for late pick-ups and deliveries.
• It is the driver’s responsibility to ensure that the load is safe, secure and legal for transport.
• Driver is required to check call daily by 10:00AM. If not, $50.00 will be charged.
• All Trailers must be clean, empty and odor free with no holes.
• Any deviation from dispatch instructions must be called in immediately.
• All products SHORTAGES must be reported at time of PICKUP. Failure to report will result in additional charges.
• Re-brokering, assigning or interlining of this shipment will void our obligation to pay your freight.
Additional Info:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________
LOAD INFORMATION
Pickup Location (PICKUP) Shipper
Address:___________________________ Name:______________________ Date:__________
___________________________________ ____________________________
Commodity: _______________________ Weight: _______________
Trailer Type: ________________________ Temperature: _________
Trailer Size: _________________________
Stop Off #1 (DELIVERY) Name:_______________________ Date: __________
Address: ____________________________ ______________________________ Time:___________
_____________________________________
Stop Off #2 (DELIVERY) Name: _______________________ Date: __________
Address: _____________________________ ______________________________ Time:___________
_____________________________________
Rate Agreed: __________________
Tarp: __________________
Extra Stop: __________________
Total: __________________
TOTAL CHARGES INCLUDE FUEL SURCHARGES
Invoicing Instructions: Settlements paid within 30 days from the date we receive your invoice. All invoices must
include a SIGNED DELIVERY RECEIPT, BOL and ORDER # and be sent to the address above.
The undersigned hereby acknowledges as correct and accepts the referenced shipment on behalf of BELLZONE FREIGHT
LOGISTICS, LLC. It is agreed that the charges indicated above include all costs and fees in connection with the shipment
as described. A minimum of $100,000.00 cargo insurance is required unless otherwise noted. Invoicing by the CARRIER
and payment by the BROKER, constitutes acceptance of this agreement and by signing, this creates a contract carriage
shipment.
THIS AGREEMENT MUST BE SIGNED AND FAXED BACK TO US AT: Fax# 1-XXX-XXX-XXXX
ACCEPTED BY:
______________________________
BellZone Freight Logistics LLC CARRIER: ____________________________
(Signature)
NAME: ____________________________
TITLE: ____________________________
To be paid: (SELECT)
_____ 30 Days
_____ Quick Pay (5%)