Nominator

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Company

US DOT Number

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Aggregate Carrier

Agricultural Commodities

Contract Carrier

Heavy Hauler

Household Movers

Less-Than-Truckload Carrier

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Over-The-Road: Nebraska Mileage & Accidents from May 1 last year through April 30 this year.

#DOT Recordable Accidents in Neb. Preventable & Non-Preventable	Mileage in Nebraska	Accident Frequency Ratio	# Non-Recordable Accidents & Incidents in Neb.	Total # of Accidents
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Local/City: Nebraska Mileage & Accidents from May 1 last year through April 30 this year.

# DOT recordable accidents in Neb. preventable & non-preventable	mileage in Neb.	accident frequency ratio	# of non-recordable accidents & incidents in Neb	total # of accidents
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Combined: Nebraska Mileage & Accidents from May 1 last year through April 30 this year.

# DOT recordable accidents in Neb. preventable & non-preventable	mileage in Neb.	accident frequency ratio	# of non-recordable accidents & incidents in Neb.	total # of accidents
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Overall Mileage & Accidents from May 1, last year, to April 30, this year. (Excludes Neb)

# DOT recordable accidents preventable & non-preventable	overall mileage	accident frequency ratio	# of non-recordable accidents & incidents	total # of accidents
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Nebraska Accident Frequency Ratio From Previous Contest Year (Combine Over-the-Road & Local/City)

Summary of Safety Program

Provide a summary of your safety program and what differentiates your company from others regarding safety. Attach a separate sheet if necessary. List type of operation, states operating in, ave. # of daily drops, and unusual challenges.

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I hereby certify that the above information is accurate to the best of my knowledge. I agree that an audit of my company’s safety records by fleet safety contest officials can be made prior to the announcement of any award. (Full name, title and date required in box below)

Fleet Safety Contest