Fillable B-1R Form - Annual Or Temporary Intrastate Credentials

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B-1R Form - Annual Or Temporary Intrastate Credentials

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  • 25 other fields

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1
B-1R FORM 2017
APPLICATION FOR ANNUAL OR TEMPORARY CREDENTIALS
SECTION 1. GENERAL INFORMATION
USDOT NO.
FEIN/SSN
NAME OF CARRIER
DOING BUSINESS AS (DBA) NAME
PRINCIPAL PLACE OF BUSINESS ADDRESS (not a PO Box) – STREET
CITY
STATE
ZIP CODE
MAILING ADDRESS (if different than Principal Address, may be a PO Box) – STREET
CITY
STATE
ZIP CODE
PERSON TO CONTACT
FAX NO.
E-MAIL ADDRESS
SECTION 2. DECAL REQUEST
Number
Fee
Amount Due
Decal Type
$10.00
Intrastate Passenger Service – Window Decals (6-12 Passengers)
$10.00
Intrastate Operations – Door Decals
$5.00
72-Hour Permit (in lieu of intrastate decal)
Staple Check Here
Total made payable to Director of Revenue
SECTION 3. UCR INFORMATION
Motor carriers operating in both interstate and intrastate commerce must file and pay fees under the Unified Carrier
Registration agreement with their base state. Intrastate renewal is not allowed for motor carriers registered with UCR.
SECTION 4. WORKERS’ COMPENSATION VERIFICATION (HOUSEHOLD GOODS MOVERS ONLY)
Check only one box:
Applicant certifies that it is compliant with Chapter 287, RSMo by procuring workers’ compensation insurance
coverage for its employees.
Applicant has permission from the Division of Workers’ Compensation to self-insure it liabilities.
Applicant has less than five employees (defined as full and part-time employees) and is exempt from procuring
workers’ compensation insurance coverage.
Note: If your company is required to obtain workers’ compensation insurance coverage and coverage lapses or is
discontinued, any household goods authority shall be subject to suspension until compliance is met.
SIGNATURE
SIGNATURE
TITLE
DATE
MISSOURI DEPARTMENT OF TRANSPORTATION
E-MAIL
contactmcs@modot.mo.gov
MOTOR CARRIER SERVICES
PHONE
1.866.831.6277
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270
FAX
573.522.6708
2
B-1R FORM INSTRUCTIONS
ONLINE RENEWAL – You can renew operating authority and request decals through MoDOT Carrier Express at
www.modot.org/mce. To obtain a user ID to access MoDOT Carrier Express, send an e-mail request to
contactmcs@modot.mo.gov.
SECRETARY OF STATE REGISTRATION – If your authority is under the name of a Limited Partnership, Limited Liability
Partnership, Limited Liability Company or Corporation, the company must be in good standing with the Missouri
Secretary of State prior to filing a renewal. You can check your status or file with the Missouri Secretary of State at
www.sos.mo.gov.
SECTION 1 – GENERAL INFORMATION
USDOT Number – A USDOT number is required for operation in intrastate commerce in the state of Missouri.
FEIN Number/Social Security Number – An FEIN number is a federal Tax ID number. A sole proprietor who does not
have an FEIN number should enter a Social Security Number.
Legal Name – This is the company name or legal name registered with the Missouri Secretary of State. This name MUST
be the same as the name registered with the FMCSA and the Missouri Secretary of State’s Office, if applicable.
Doing Business As (DBA) Name – A DBA is a name that a company may use that is different from their legal company
name. If using a DBA name, it MUST be registered with the Missouri Secretary of State. Fictitious name registrations can
be filed online at www.sos.mo.gov or by calling 1.866.223.6535.
Principle Place of Business – The principle place of business address is the location where the safety records of the
company are kept or can be made available. This must be a physical location, not a PO Box.
Mailing Address – Enter the mailing address if different than the principal place of business address. This address may
be a PO box.
SECTION 2 – DECAL REQUEST
Number – Enter the number of each type of decal you are requesting.
Amount Due – Enter the total due (number times fee) for the type of decal you are requesting.
Intrastate Passenger Service
Window Decal
Required for carriers transporting passengers wholly within Missouri whose
vehicles have a seating capacity of 6 to 12 passengers.
Intrastate Operations
Door Decal
Required for carriers transporting property wholly within Missouri or carriers
transporting passengers wholly within Missouri whose vehicles have a seating
capacity of more than 12.
72-Hour Permit
This permit takes the place of an intrastate decal. This permit DOES NOT
replace the requirement for intrastate operating authority. Applicant MUST
hold active intrastate authority.
SECTION 3 – UCR INFORMATION
Motor carriers operating in both interstate and intrastate commerce must file and pay fees under the Unified Carrier
Registration agreement. Intrastate renewal is not allowed for motor carriers registered with UCR.
SECTION 4 – WORKERS’ COMPENSATION VERIFICATION
This section is ONLY to be completed by motor carriers transporting household goods. Select the appropriate box
indicating the status of your workers’ compensation insurance.
SECTION 5 – SIGNATURE
Verify the B-1R is complete and accurate. Provide your signature, title and date.
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B-1R Form - Annual Or Temporary Intrastate Credentials

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Completed 20 July 2020

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