Quick Quote - CIS Fuel Marketers Insurance Trust

Are you a current MPCA member?*

Yes
No

Are you a current MGA member?*

Yes
No

Do you have a current Agent?*

Yes
No

Agent / Company Name*

Your Company Information

Company Name*

Phone*

Contact Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Main Business Location*

Street Address Address Line 2 City State ZIP Code

Officers / Principals*

Officer / Principal	Include?

Contact Person / Title*

Status*

Corp
Partner
Sole P.
LLC

Description of Operations*

Policy Effective Date*

FEIN*

Years in Business Under Current Ownership

Current Experience Mod

Class Code and Payroll Information

Class Code	Payroll	Manual Rate*	Premium*	Total # of Employees	# of Part Time Employees	# of Full Time Employees

Target Premium Requested:

Prior Loss History

Year	Carrier	Number of Claims	Paid	Reserved	Total Incurred	Any Claims?

Upload Loss Runs Referenced Above

Drop files here or

Max. file size: 16 MB.

Questionnaire

Details MUST be provided for all “Yes” answers given below

1. Does applicant own, operate, or lease aircraft/watercraft?*

Yes
No

2. Any exposure to flammables, explosives, or caustic fumes?*

Yes
No

3. Any work performed underground or above 15 feet?*

Yes
No

4. Any work performed on barges, vessels, docks, or bridges?*

Yes
No

5. Is applicant engaged in any other type of business?*

Yes
No

6. Are subcontractors used?*

Yes
No

7. Any work sublet without Certificates of Insurance?*

Yes
No

8. Is a formal safety program in operation?*

Yes
No

9. Any group transportation provided?*

Yes
No

10. Any part-time or seasonal employees?*

Yes
No

11. Is there any volunteer or donated labor?*

Yes
No

12. Do employees travel out of state?*

Yes
No

13. Do operations involve storing, treating, discharging, applying, disposing, or transporting of hazardous material – i.e., landfills, asbestos, wastes, fuel tanks, etc.?*

Yes
No

14. Does applicant have armed guards?*

Yes
No

15. Any operations outside of Missouri?*

Yes
No

16. Does applicant lease employees?*

Yes
No

17. Do operations involve steel erection over three (3) stories?*

Yes
No

18. Any employees under 16 or over 60 years of age?*

Yes
No

19. Any employees with physical handicaps?*

Yes
No

20. Any athletic team sponsored?*

Yes
No

21. Are physicals required after offers of employment are made?*

Yes
No

22. Do employees predominately work from home?*

Yes
No

List Number of Employees that Work from Home

23. Any tax liens or bankruptcies in the last 5 years?*

Yes
No

24. Any undisputed and unpaid workers’ compensation premium due from you or any commonly owned or managed enterprises?*

Yes
No

Explain undisputed and unpaid workers’ compensation premium including entity name(s) and policy number(s).

If "Yes" to any of the above please provide details:

The Quick Quote is designed to give the applicant an estimate of their contributions based upon payroll and loss information provided at the time of the survey and is subject to revision and approval by the Excess Carrier and the Fuel Marketers Insurance Trust Board of Trustees. The Quick Quote is for informational purposes only. Trust premium could be affected by dividends or assessments. This Quick Quote is not for purposes of binding coverage.

Apply Now – Quick Quote

Your Company Information

Class Code and Payroll Information

Questionnaire

Phone: (844) 804-1789