Quick Quote
Administered by Alternative Risk Services, LLC

Alternative Risk Services

10525 NW Ambassador Drive Suite 301

Kansas City, MO 64153

888-816-3003 Phone

816-412-4501 Fax

Are you a current MPCA member? YesNo

Company Name:    * Required Mailing Address:    * Required City:    * Required State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   * Required Zip:    * Required Telephone:    * Required e-mail:     * Required (quote will be sent to this address)

Main Business Location:    * Required Officers/Principals:  Contact Person/Title:    * Required Status:  CorporationPartnershipSole Proprietorship   Description of Operations:  FEIN:  Years in Business Under Current Ownership:    Policy Effective Date:     * Required Current Experience Mod:    * Required

Prior Loss History: Year Carrier Number of Claims Total Incurred (Claim Cost) Premium Loss Ratio 2012 * Required 2011 * Required 2010 * Required 2009 * Required

Details MUST be provided for all “Yes” answers given below: Does applicant own, operate or lease aircraft/watercraft?  YesNo   * Required  Any exposure to flammables, explosives or caustic fumes?  YesNo   * Required  Any exposure to radioactive materials?  YesNo   * Required  Any work performed underground or above 15 feet?  YesNo   * Required  Any work performed on barges, vessels, docks or bridges?  YesNo   * Required  Is applicant engaged in any other type of business?  YesNo   * Required  Are subcontractors used?  YesNo   * Required  Any work sublet without Certificates of Insurance?  YesNo   * Required  Is a formal safety program in operation?  YesNo   * Required  Any group transportation provided?  YesNo   * Required  Any part-time or seasonal employees?  YesNo   * Required  Is there any volunteer or donated labor?  YesNo   * Required  Do employees travel out of state?  YesNo   * Required  Any coverage declined/canceled /non-renewed (last three years)?  YesNo   * Required  Wrecking or demolition of structures?  YesNo   * Required  Do operations involve storing, treating, discharging, applying, disposing or transporting of hazardous material – i.e. landfills, asbestos, wastes, fuel tanks, etc.?  YesNo   * Required  Do operations include ambulance or emergency vehicle?  YesNo   * Required  Does applicant have armed guards?  YesNo   * Required  Does applicant provide home health care?  YesNo   * Required  Any operations outside of Missouri?  YesNo   * Required  Does applicant lease employees?  YesNo   * Required  Do operations involve steel erection over three (3) stories?  YesNo   * Required

Class Code and Payroll Information: Class Code Payroll Number of Employees 83 - Cattle Livestock - NOC 3724 - Machine/Equip Erect & Repair 5057 - Iron/Steel Erection - NOC 5538 - Sheet Metal Worker - NOC 6836 - Marina 7228 - Trucking - Local Haul Only 7229 - Trucking - Long Distance Haul 7380 - Drivers 8006 - Grocery Store 8008 - Store - Clothing Retail 8017 - Store: Retail - NOC 8018 - Store: Warehouse-NOC 8033 - Store: Meat, Grocery and Provision Combined 8061 - Store: Grocery - Conv - Retail 8203 - Ice Dealer/Driver 8292 - Warehouse - NOC 8350 - Gas/Oil Dealer 8353 - Gas Dealer - Lpg 8381 - Gas Station - Self Service 8387 - Gas Station - Retail 8391 - Auto Repair 8742 - Salesperson, Outside 8748 - Auto Sales 8810 - Clerical 9015 - Maintenance - NOC 9052 - Motel 9082 - Restaurant - Fast Food 9083 - Restaurant - NOC 9519 - Electrical - Service or Repair & Drivers   * Required

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.