Renewal Applicationadmin2021-11-02T14:32:57+00:00

Renewal Application

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*
Contact Person / Title*
Status*
- Corp
- Partner
- Sole P.
Class Code and Payroll Information
Classification Description Class Code Estimated Payroll # of Employees
Number of Part Time Employees*
Number of Seasonal Employees*
Number of Employees Under Age 16*
Number of Employees Over Age 60*
If you have any volunteer or donated labor, please describe their duties:*
Please list affiliated companies, subsidiaries, and divisions to be included in the program, if any
Name Principal Address (City, State, Zip) Type of Business
Vehicle Information
# Of Drivers # of Owned or Leased Vehicles Passenger Car # of Vans or Trucks Tractors Trailers
Describe Use of Trucks:*
Type of Goods Hauled:*
Radius of Travel
Primary States Average Mileage Maximum Mileage Average # Persons Per Vehicle Max # Persons per Vehicle
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 exposure to radioactive materials?*
- Yes
- No
4. Any work performed underground or above 15 feet?*
- Yes
- No
5. Any work performed on barges, vessels, docks, or bridges?*
- Yes
- No
6. Is applicant engaged in any other type of business?*
- Yes
- No
7. Are subcontractors used?*
- Yes
- No
8. Any work sublet without Certificates of Insurance?*
- Yes
- No
9. Is a formal safety program in operation?*
- Yes
- No
10. Any group transportation provided?*
- Yes
- No
11. Any part-time or seasonal employees?*
- Yes
- No
12. Do you use independent owner/operators*
- Yes
- No
13. Do you require owner/operators to purchase their own coverage?*
- Yes
- No
14. Do you request and keep Certificates of Insurance on file for owner/operators?*
- Yes
- No
15. Is there any volunteer or donated labor?*
- Yes
- No
16. Do employees travel out of state?*
- Yes
- No
17. Any coverage declined/canceled /non-renewed (last three years)?*
- Yes
- No
18. Wrecking or demolition of structures?*
- Yes
- No
19. Do operations involve storing, treating, discharging, applying, disposing, or transporting of hazardous material – i.e., landfills, asbestos, wastes, fuel tanks, etc.?*
- Yes
- No
20. Do operations include ambulance or emergency vehicle?*
- Yes
- No
21. Does applicant have armed guards?*
- Yes
- No
22. Have you been cited for any OSHA violations?*
- Yes
- No
23. Any operations outside of Missouri?*
- Yes
- No
24. Does applicant lease employees?*
- Yes
- No
25. Do operations involve steel erection over three (3) stories?*
- Yes
- No
If "Yes" to any of the above please provide details:
Please provide a list of Owner / Operators who are covered by FMIT
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE
Survey completed by:
Date
Month
Day
Year
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.
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Classification Description	Class Code	Estimated Payroll	# of Employees

Name	Principal Address (City, State, Zip)	Type of Business

# Of Drivers	# of Owned or Leased Vehicles	Passenger Car	# of Vans or Trucks	Tractors	Trailers

Primary States	Average Mileage	Maximum Mileage	Average # Persons Per Vehicle	Max # Persons per Vehicle

Renewal Application

Your Company Information

Class Code and Payroll Information

Vehicle Information

Questionnaire

Phone: (844) 804-1789