Fillable NEW VENDOR REQUEST FORM Dear Vendor Partner, Please

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NEW VENDOR REQUEST FORM Dear Vendor Partner, Please

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Dear Vendor Partner,
Please return the completed forms to have a vendor number assigned. Our requirements
are outlined in the checklist below.
☐ New Vendor Request Form
☐ Contact Info Form
☐ Vendor ACH Payment Authorization Form
☐ W-9
☐ Certificate of Insurance, meeting requirements below:
• General Liability: $1,000,000 per occurrence minimum, $2,000,000 general
aggregate
o WOW Logistics listed as an additional insured
• Automobile Liability: $1,000,000 combined single limit, “Any Auto” box is
checked
o WOW Logistics listed as an additional insured
• Workers Compensation: statutory limits, “Per Statute” box is checked
☐ Review WOW Logistics Vendor and Purchase Order Terms and
Conditions at: www.wowlogistics.com/vendor-terms
NEW VENDOR REQUEST FORM
Please note: An active vendor number is required before any purchases or services
can be completed.
NEW VENDOR REQUEST FORM
Company Name
Physical Address
Street
City State Zip
Remittance Address (if different)
Street
City State Zip
Phone Tax ID SCAC (if applicable)
Accounts Receivable Contact
Name
Email
Phone
Payment Terms: Net 30 Days 10-Day Express-2% Program
Preferred Payment Method:
Check
EFT
(complete Vendor ACH Payment Authorization form next page)
Transportation Vendors: Do you use a factoring company to process invoices and payments?
No
Yes-complete below information
Name of Factoring Company
Street
City State Zip
Do you or your company have a relationship with an owner or employee of WOW Logistics
or any of it's affiliates? No Yes. If yes, who and what is the relationship:
Company Website
WOW Department Manger Approval:_______________
___
Approval Date: __________
Company Principal Contact*
Name/Title
Address
Phone
Email
*Owner, CEO/President of Company
Company Salesperson Contact
Name
Address
Phone
Email
Company Customer Service Contact
Name
Address
Phone
Email
Company Purchase Order Contact
Name
Address
Phone
Email
Wow Internal Use:
Department:_____________________
Vendor Type:_____________________
VENDOR ACH PAYMENT AUTHORIZATION FORM
WOW Logistics Company pays invoices electronically rather than by check. Your payments will be deposited
electronically into a checking or savings account of your choice. Please complete this form and return to
AP@WOWLogistics.com or mail to:
WOW Logistics Company
1450 McMahon Drive
Neenah, WI 54956
AUTHORIZATION
By completing, signing, and returning this form (attaching a voided check is recommended but not required), you
authorize WOW Logistics Company to initiate payment to your checking or savings account at the financial
institution listed below. In the event WOW Logistics Company erroneously initiates payment to the account listed
below and to which such payment you are not entitled to, WOW Logistics Company will notify you and you shall
notify the financial institution to return said payment to WOW Logistics Company. This authorization will remain in
effect until WOW Logistics Company receives written notice of cancellation from you in such a manner of time so
as to afford WOW Logistics Company and the financial institution a reasonable opportunity to act on it.
PAYEE INFORMATION
Payee Name
BANK INFORMATION
Account Type
Checking
Savings
Bank Name
Bank Address
Name on Account
Routing #
Account #
Remittance Email
I certify that I am an authorized user of the account listed above and will not dispute these scheduled transactions with my
financial institution; so long as the transactions correspond to the terms indicated in this authorization form. If payment is
initiated on a weekend or holiday, you understand that the payment may be executed or received on the next business day.
You agree that no prior-notification will be provided with respect to each initiated payment. Any loss of data will be borne by
you unless the loss is due to WOW Logistics Company's gross negligence. WOW Logistics Company shall be permitted to rely
on the information supplied by you on this authorization form and you agree to indemnify, defend and hold WOW Logistics
Company harmless for any damages arising out of your failure to properly change the information and provide notification
with respect to such change. WOW Logistics Company shall not be liable for any incidental, consequential, indirect, or special
damages arising out of initiating payment or your failure to timely receive any payment, including but not limited to interest
charges or lost profits. WOW Logistics Company's maximum liability for any erroneous payment made hereunder is the
amount of the payment.
NAME: TITLE:
DATE:
Authorized Signature
Employer identification number
–
Part I
Taxpayer Identification Number (TIN)
tity, see the Part I instructions on page 3. For other
Social security number
–
–
TIN on page 3.
or
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
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); and
4.
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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 3.
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov/fw9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number (SSN), individual taxpayer identification
number (ITIN), adoption taxpayer identification number (ATIN), or employer
identification number (EIN), to report on an information return the amount paid to
you, or other amount reportable on an information return. Examples of information
returns include, but are not limited to, the following:
•
Form 1099-INT (interest earned or paid)
•
Form 1099-DIV (dividends, including those from stocks or mutual funds)
•
Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
•
Form 1099-B (stock or mutual fund sales and certain other transactions by
brokers)
•
Form 1099-S (proceeds from real estate transactions)
•
Form 1099-K (merchant card and third party network transactions)
•
Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
(tuition)
•
Form 1099-C (canceled debt)
•
Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might be subject
to backup withholding. See What is backup withholding? on page 2.
By signing the filled-out form, you:
1.
Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2.
Certify that you are not subject to backup withholding, or
3.
Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your 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, and
4.
Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
Cat. No. 10231X
Form
W-9 (Rev. 12-2014)
Sign
Here
Signature of
U.S.person
a
Date
a
Pr
i
nt
or
type
See
Spec
i
fic
I
nstruct
i
ons
on
page
2.
F
orm
W-9
(Rev. December 2014)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate
single-member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
a
Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
the tax classification of the single-member owner.
Other (see instructions)
a
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
E-MAIL
ADDRESS:
INSURER A :
INSURED
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER
POLICY EFF POLICY EXP
TYPE OF INSURANCE LIMITS
(MM/DD/YYYY) (MM/DD/YYYY)
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE OCCUR
$
PREMISES (Ea occurrence)
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PRO-
POLICY LOC
PRODUCTS - COMP/OP AGG
JECT
OTHER: $
COMBINED SINGLE LIMIT
$
(Ea accident)
ANY AUTO
BODILY INJURY (Per person) $
OWNED SCHEDULED
BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
HIRED NON-OWNED
PROPERTY DAMAGE
$
AUTOS ONLY AUTOS ONLY
(Per accident)
$
OCCUR
EACH OCCURRENCE
CLAIMS-MADE
AGGREGATE $
DED RETENTION $
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below
INSURER(S) AFFORDING COVERAGE NAIC #
COMMERCIAL GENERAL LIABILITY
Y / N
N / A
(Mandatory in NH)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
$
$
$
$
$
The ACORD name and logo are registered marks of ACORD
8/11/2019
(
920) 123
-4
567
(920) 123-
5678
12345
Name of Vendor Here
Address
City, State Zip Code
A
1,000,000
X
ZA7341 7/21/2019 7/21/2020
300,000
10,000
1,000,000
2,000,000
3,000,000
ERRORS OMISSION 100,000
1,000,000
A
X
ZA7341 7/21/2019 7/21/2020
3,000,000
A
ZA7341 7/21/2019 7/21/2020
3,000,000
10,000
A
ZA7341 7/21/2019 7/21/2020
100,000
Y
100,000
500,000
A
Equipment Floater ZA7341 7/21/2019
Leased/Rented 75,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
WOW Logistics is an additional insured with respect to general liability per and auto liability.
WOW Logistics
1450 McMahon Dr
Neenah, WI 54956
SECUOVE-01
PRODUCER
ABC Insurance Agency
1234 5th Street
Marshfield, WI 54449
Bob Smith
Bob.Smith@abcinsurance.net
Acuity
X
7/21/2020
X
X
X
X
X
X
X
EXAMPLE ONLY
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NEW VENDOR REQUEST FORM Dear Vendor Partner, Please

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Completed 1 July 2021

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