Renewal Application

  • Your Company Information

  • Class Code and Payroll Information

  • Classification DescriptionClass CodeEstimated Payroll# of Employees 
  • NamePrincipal Address (City, State, Zip)Type of Business 
  • Vehicle Information

  • # Of Drivers# of Owned or Leased VehiclesPassenger Car# of Vans or TrucksTractorsTrailers 
  • Primary StatesAverage MileageMaximum MileageAverage # Persons Per VehicleMax # Persons per Vehicle 
  • Questionnaire

    Details MUST be provided for all “Yes” answers given below
  • Survey completed by:
  • 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.