Transportation Provider Information Form

Please complete the form below. If you have any issues you can print out the form and fax it to us at 602.200.5505. Thank you.

In order to complete this process please also download and complete our Letter of Intent Form. Upon completion, please email the form to bdadmin@totaltransit.com

Company
Company Website
Street Address
City
State
Zip
Phone
Fax
E-mail Address
National Provider Identification Number (NPI)
Individual Authorized to Enter Company into Contractual Obligations
Title
Phone Number
E-Mail Address
Counties in which you operate
Languages spoken other than English
Service Area:
Hours of Operation
24/7: Sunday: Monday: Tuesday:
Wednesday: Thursday: Friday: Saturday:
Please tell us how many of each type of vehicle you have and the rates for each
Ambulatory Wheelchair Stretcher
Bariatric Wheelchair Bariatric Stretcher
Ambulatory Drop Rate
Ambulatory Mileage Rate
Wheelchair Drop Rate
Wheelchair Mileage Rate
Bariatric Drop Rate
Bariatric Mileage Rate
Stretcher Drop Rate
Stretcher Mileage Rate
Bariatric Wheelchair Drop Rate
Bariatric Wheelchair Mileage Rate

Current Number of Drivers
Do you train, perform background and drug tests, and evaluate drivers or employees?
Do you have automobile insurance of at least $1,000,000?
If no, What are your limits at?
Do you have general liability insurance of at least $1,000,000?
If no, What are your limits at?
Do you have workers comp insurance of at least $1,000,000?
If no, What are your limits at?
   
 
What 2-way system/technology do you use to communicate with drivers?:
Any Additional Information that will help us understand the transportation market or your company.
Please include if you currently do NEMT trips and an average number of trips per month:
Total Transit is currently operating a smartphone app for business-to-consumer, direct-to-driver dispatch (RideShare) and we are rapidly working on expanding the application for business-to-business use. Use of this technology dramatically increases the efficiency of the dispatching process but requires the driver to have an approved smartphone.
What are your thoughts on this technology and its applicability to improving your business?:
Are you a Minority or Women Owned Business Enterprise (MBE/WBE)
If so are you registered?