Vendor Form

VENDOR FORM
Request Type:
Are you a Keystone Cooperative Employee:
Employee Request:
Vendor Type:
Will you need to come onto Keystone property to complete your services:
Will you be working with Keystone as a Broker or a Carrier:
Vendor Classification:
Request Type (Applicator):
Request Type (Contractor):
Request Type (Internal):
IMPORTANT – In order to be approved as a vendor of Keystone Cooperative, and before you may provide any goods or services to Keystone, this form must be filled out in its entirety and be approved by an authorized Keystone representative. Approval is conditional upon your completion of any required documents requested by Keystone, such as completion of a contractor or other packet, execution of approved contracts, and submission of proof of insurance. Our individual branches have been informed that they cannot engage a vendor without this form being approved and on file at Keystone’s corporate office.
KEYSTONE EMPLOYEE INFO
Name:

First NameLast Name
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Location:
Division(s):
VENDOR INFO
Contact Name:

First NameLast Name
Vendor / Company Name:
Company Name or First & Last Name if company name is available.
Phone Number:
Format: (000) 000-0000.
Cell Number:
Format: (000) 000-0000.
Contact Email:
example@example.com
Website:
Company Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attach W-9:

Cancelof
Name of Keystone employee that you're currently working with:

First NameLast Name
Description of Services:
Do you have a Certificate of Insurance (COI)?
Which company are you working with:
VENDOR PAYMENT INFO
Remittance Address Same As Physical:
Remittance Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Remit Email Same as Contact Email:
Remit Email:
example@example.com
ACH Setup - Automatic Clearing House
Take advantage of the simplicity, convenience, and efficiency of ACH payments by scheduling your payments to get automatically deposited into your bank account.

Why Choose ACH payments:
• For simplicity: Allows for less processing
• For convenience: Saves time and reduces paper waste
• For effiency: Promotes on time payments and less risk of payments getting lost

How ACH Payments Work:
You authorize deposits into your bank account. Your account will be credited
the amount indicated on your invoice to our company.
Sign Up For ACH:
Account Type:
Name on Account:
Bank Name:
Bank City / State:

Street Address

Street Address Line 2

CityState

Zip Code
Bank Routing Number:
Bank Routing Number (Confirm):
Routing Number Matches!
Routing Number Does Not Match!
Account Number:
Account Number (Confirm):
Account Number Matches!
Upload Voided Copy of Check:

Not Required - Used in case account or routing number is incorrect.
Cancelof
Account Number Does Not Match!
Terms:

I/we authorize Keystone Cooperative, Inc. to deposit to the bank account listed above for payment of its obligations.

I/we understand and agree that any and all changes in my acount information, including requests to terminate this agreement, must be in writing and delivered to company at the above address at least 21 days prior to the next
due date. If the payment due date falls on a weekend or holiday, I/we understand that the payment may be executed on the next business day. I/we agree to fully cooperate with company to correct any processing errors that may occur.

ACH set up could take up to 30 days.
Printed Name:

First NameLast Name
Title:
APPLICATOR INFO
Applicator Type:
Chemical Type:
Below is a list of items that must be attached to the new vendor form to approve your company for the current Aerial Application Season (even if you submitted them previously).
- FAA Part 137 License (actual Operating Certificate)
- Commercial Business Pesticide License Category 11
- Part 107 UAS License (for all drone applicators)
- Pesticide Applicator License Category 11 (for all applicators)
- FAA Airman Class 3 Medical Exam-Drone, Class 2 Medical Exam-Plane/Helicopter (for all applicators)
Also please include any prepay invoices at this time.
Upload copies of the documents here:

Cancelof
Please click the links below to complete the Application Service Agreement & Aerial Applicator Guidelines. Once completed, come back to this form to complete the vendor setup:

Application Services Agreement

Aerial Applicator Guidelines
If you received the Thank You confirmation page, your submission was successful. Please complete the form again only if a correction is required.
CONTRACTOR INFO
What type of products will transported:
What type of services will be performed:
Which Keystone locations will be serviced:
Do You Normally Use Sub-Contractors:
INSURANCE REQUIREMENTS

Keystone will identify the specific required insurance in the minimum coverage limits as set forth below.
Certificate of Insurance Minimum Coverage (as specifically identified by Keystone):
- Employer's Liability: $500,000 Each Accident; $500,000 Policy Limit; $500,000 Employee Limit Disease
- General Liability: $1,000,000 Per Occurrence / $2,000,000 Aggregate; Products – Comp/OP$2,000,000 Aggregate
- Auto Liability: $500,000 Combined Single Limit (CSL)
- Workers Compensation: Statutory for State/Territory
- Property damage coverage (Collision and Comp) for non-owned trailers if not already covered by your policy.
- Additional insurance coverage may be required. The above coverage is Keystone's minimum requirement.
Additional Requirements:
- Coverage has to be placed with insurance with a minimum AM Best rating of A- VII
- 30 days' notice of cancellation or nonrenewal provided to Keystone Cooperative, Inc.
Waiver of Subrogation: Subrogation rights must be waived in favor of Keystone Cooperative, Inc.

Additional Insured: Policies maintained shall include an endorsement naming Keystone Cooperative, Inc. as Additional Insured in the areas of General Liability and Auto Liability. The insurance coverage must be Primary Non-Contributory with respect to the named Additional Insured. Proposed language to be included on the COI is as follows:

The certificate holder is an additional insured with respect to the general liability & auto liability coverage, which is primary coverage to the additional insured and other available insurance will be non-contributory as required by written contract.

The name and address on the Certificate of Insurance for the "certificate holder" should be:

Keystone Cooperative, Inc.
770 North High School Road
Indianapolis, IN 46214
Certificate of Insurance Minimum Coverage (as specifically identified by Keystone):
The certificate holder is an additional insured with respect to the general liability & auto liability coverage, which is primary coverage to the additional insured and other available insurance will be non-contributory as required by written contract.

The name and address on the Certificate of Insurance for the "certificate holder" should be:

Keystone Cooperative, Inc.
770 North High School Road
Indianapolis, IN 46214
Additional Insured:
Waiver of Subrogation:
Additional Requirements:
Additional Cargo Coverage:
Additional Aerial / Drone Minimum Coverage:
Are you exempt from carrying workers compensation coverage?
Upload Worker's Comp Exemption Documentation:

Cancelof
Upload COI - Certificate of Insurance:

Cancelof
CONTRACTS
All agreements, terms, quotes, order forms, statements of works, proposals, and other documents outlining the arrangement between the vendor and Keystone must be submitted and approved by Keystone’s Legal department prior to any work being performed and/or any goods being provided, as well as any payments being made to vendor.
Description of Contract:
Put "No Contracts" if not applicable.
Please attach all contracts and supplementary documents (e.g., proposals, order forms, SOWs, invoices etc.):

Cancelof
ACKNOWLEDGEMENTS
I acknowledge that I have completed this form completely and accurately.
I acknowledge that I have completed this form completely and accurately.

All invoices and statements should be sent via email to AP@keystonecoop.com.
If invoices are mailed, please mail to:

Keystone Cooperative Inc.
770 N High School Rd
Indianapolis, IN 46214

I acknowledge that vendors cannot provide goods or services to Keystone, or receive payment, until this form, and all required documents, have been accepted and approved by an authorized representative of Keystone Cooperative, Inc.
Please verify that you are human:
Signature:
Date:

MonthDayYear
Date
Application Reference:
Should be Empty:

VENDOR FORM

KEYSTONE EMPLOYEE INFO

VENDOR INFO

VENDOR PAYMENT INFO

ACH Setup - Automatic Clearing House

APPLICATOR INFO

CONTRACTOR INFO

INSURANCE REQUIREMENTS

CONTRACTS

ACKNOWLEDGEMENTS