Company Information

Individual Authorized to Enter Company into Contractual Obligations

First Name:*

Last Name:*

Title:

Company Name and Information

Company:*

Street:*

City:*

State/Province:*

Zip/Postal Code:*

Country:*

Website:

Phone:*

Mobile:

Fax:

Email:*

National Provider Ident. Number:

Minority Business Enterprise (MBE):

Woman-owned Business Enterprise (WBE):

Disadvantaged Business Enterprise (DBE):

Small Business Enterprise (SBE):

Vehicles and Drivers

Number of Drivers:*

Daily Trip Capacity:*

Qty of Ambulatory Vehicles:*

Ambulatory Drop Rate ($):

Ambulatory Mileage Rate ($):

Qty of Wheelchair Vehicles:*

Wheelchair Drop Rate ($):

Wheelchair Mileage Rate ($):

Qty of Bariatric Wheelchair Vehicles:*

Bariatric Wheelchair Drop Rate ($):

Bariatric Wheelchair Mileage Rate ($):

Qty of Bariatric Stretcher Vehicles:*

Bariatric Stretcher Mileage Rate ($):

Bariatric Stretcher Drop Rate ($):

Qty of Non-Emergency Stretcher Vehicles:*

Non-Emergency Stretcher Drop Rate ($):

Non-Emergency Stretcher Mileage Rate ($):

Qty of Ambulance Vehicles:

Ambulance Drop Rate ($):

Ambulance Mileage Rate ($):

Insurance

NEMT contracts can require up to $1 million in auto and general liability insurance,
as well as other coverage (unemployment, professional liability). Are you willing and able to meet
contract requirements?

Yes, I can meet contract requirements:*

Do you have automobile insurance of at least $1,000,000?:

If no, what are your auto insurance 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?:

Operations

What 2-Way system/technology do you use to communicate with drivers?:

Are you willing and able to meet the driver (training, background, drug tests, etc.) and
vehicle (maintenance, appearance, etc.) anticipated in an NEMT contract?

Yes, I’m willing and able:*

Hours of Operation Please check the days you are open and the corresponding business hours.

Are you available 24/7?:

Monday Hours:

Monday Open:

Monday Close:

Tuesday Hours:

Tuesday Open:

Tuesday Close:

Wednesday Hours:

Wednesday Open:

Wednesday Close:

Thursday Hours:

Thursday Open:

Thursday Close:

Friday Hours:

Friday Open:

Friday Close:

Saturday Hours:

Saturday Open:

Saturday Close:

Sunday Hours:

Sunday Open:

Sunday Close:

Counties in which you operate:

Other Languages Spoken:

Service Area:*

Additional Information

Signature Authorization

Individual Authorized to Enter Contracts:*

Letter of Intent to Participate in the Veyo Non-Emergency Medical Transportation Provider Network

To Whom It May Concern: Veyo has requested our participation as an NEMT transportation provider in areas that we provide services and my company will consider contracting with them to provide these NEMT services. We understand that any contract we enter into with Veyo, for services under an NEMT program, will be subject to the rules and regulations of the specific contract(s) that Veyo enters into with its clients and/or the health care providers. This Letter of Intent indicates only our willingness to consider providing transportation services under a future contract and does not bind either my company or Veyo to any particular terms or conditions.

By submission of this form, I attest that the information contained in this form is accurate and complete to the best of my knowledge at this time.

Do you authorize Veyo to use the name of your company in planned or future business proposals?:

Electronic Signature (please enter your first and last name):*

By checking, you consent to the use of an electronic signature:*