USA Decommissioning Business Information Request Form

Business Name*

Contact/Representative Name*

First Last

Email Address*

Office Phone*

Cell Phone

Website

Business HQ Address*

Street Address Suite/PO Box/Building City State ZIP Code

Accounting Department Address*

Same as previous

Street Address Suite/PO Box/Building City State ZIP Code

Accounts Payable Contact

First Last

Accounts Payable Email Address

Accounts Payable Phone*

REQUIRED DOCUMENT – Certificate of Insurance

Because you will be working onsite, we need to obtain a certificate of insurance naming USA DECOMMISSIONING LLC as Additional Insured. We require proof of liability, auto, and workers comp insurance. If your COI isn’t available when you’re completing this form, please have it sent to accounting@usadecom.com. Our company information for the COI is: USA Decommissioning LLC, 9901 Brodie Lane, Ste 160-605, Austin, TX 78748.

Upload Certificate of Insurance

Max. file size: 256 MB.

Name

This field is for validation purposes and should be left unchanged.

Equipment Buyer Information Request Form

REQUIRED DOCUMENT – Certificate of Insurance