Commercial Auto Submission SUBMIT ONLINEBroker Name*Agency Name*Broker Phone:*Broker Primary Email:* Primary Name Insured:*Entity Type:*Type of Business:* INSURED/APPLICANT INFORMATIONDo operations involve transporting hazardous materials such as flammables or explosives?* Yes No Please explain:*Do operations involve transporting chemicals other than for pool or pest control?* Yes No Please explain:*Do operations involve work in another state for more than 90 days per year?* Yes No Please explain:*Any policy or coverage declined, cancelled or non-renewed during the prior 3 years, other than for non-payment of premium?* Yes No Please explain:*Any vehicles owned but not scheduled on the application?* Yes No Please explain:*Are any vehicles not solely owned by and registered to the applicant?* Yes No Does the applicant own the majority in any other business not listed on the application?* Yes No Please explain:*Does the applicant carry a General Liability or Businessowner policy?* Yes, with another carrier Yes, with Mercury No Other carrier name:*Does the applicant carry a Mercury Personal Auto policy?* Yes No Has the applicant carried continuous auto insurance for the past 12 months?* Yes No Please explain lapse in coverage - including how long of a lapse:*Desired Effective Date* MM slash DD slash YYYY Select closest prior liability limit:*<$100,000 CSL$100,000 CSL$300,000 CSL$500,000 CSL$750,000 CSL$1,000,000 CSLAre state insurance filings required on this policy?* Yes No Enter year business was started:*Primary Named Insured:*Entity type:*CorporationIndividualLLCPartnershipType of Business:*Owner, Officer or Partner responsible for management of business:* First Last Primary address: PROGRAM ONLY AVAILABLE IN FOLLOWING STATES - AZ, FL, GA, IL, NV, OK, TX and VA* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone:*Additional Named Insureds*NameRelationship to Primary Named Insured CREDIT INFORMATIONIn connection with this quote or application for insurance, Mercury may review your credit report for rating or underwriting purposes, or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party, such as a consumer reporting agency, in connection with the development of your insurance score. If you believe the information in your credit report is inaccurate, you may request that your information be updated. On your request, Mercury will reevaluate you based on corrected credit information from a consumer reporting agency. To ensure report accuracy, please verify the following information BEFORE retrieving your Credit Score. Credit application choice:*I want to enter my credit scoreI want to run a credit reportName* First Last Date of birth:* MM slash DD slash YYYY Social Security*Credit holder address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Enter credit level*AveragePoorFairGoodExcellent COVERAGELiability Limit:*$100,000 CSL$300,000 CSL$500,000 CSL$750,000 CSL$1,000,000 CSLUninsured Motorists Bodily Injury:*$100,000 CSL$300,000 CSL$500,000 CSL$750,000 CSL$1,000,000 CSLAdditional coverages Hired Auto Liability Broadening Endorsement (INCLUDES: Fellow Employee, Employees as Insureds, Employee Hired Autos, Blanket Additional Insured & Blanket Waiver of Subrogation Coverage) Hired Auto Physical Damage Non Owned Auto Liability Driver Other Car Coverage UMPD/CWC VEHICLE INFORMATIONFleet Status*1 Vehicle2 Vehicles3 Vehicles4 Vehicles5 Vehicles6 VehiclesBase State*AZCAFLGAILNVOKPATXVAVEHICLE #1 INFORMATIONVehicle #1 VIN number*Vehicle #1 Description*YearMakeModelGaraging Zip CodeVehicle #1 Description of vehicle use? Please provide details.*Does Vehicle #1 have an Anti -Theft Device?* Yes No Vehicle #1 Usage*Business OnlyBusiness and PersonalIs Vehicle #1 used for deliveries or to pick up goods?* Yes No Vehicle#1 Average number of jobsites and errands per day?*Vehicle #1 average daily radius?*Up to 50 milesUp to 100 milesUp to 200 milesUp to 500 miles500+ milesVehicle #1 Ownership*Owned by InsuredOwned by EmployeeVehicle #1 - Is there additional equipment for vehicle?* Yes No Vehicle #1 Loss Payee required?* Yes No Vehicle #1 Comprehensive Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #1 Collision Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #1 Rental Reimbursement*No Coverage$30 per day/30 days max$40 per day/30 days max$50 per day/30 days max$70 per day/30 days max$100 per day/30 days maxVehicle #1 Towing Reimbursement*No Coverage$35$50$100VEHICLE #2 INFORMATIONVehicle #2 VIN number*Vehicle #2 Description*YearMakeModelGaraging Zip CodeVehicle #2 Description of vehicle use? Please provide details.*Does Vehicle #2 have an Anti -Theft Device?* Yes No Is Vehicle #2 used for deliveries or to pick up goods?* Yes No Vehicle #2 Usage*Business OnlyBusiness and PersonalVehicle#2 Average number of jobsites and errands per day?*Vehicle #2 average daily radius?*Up to 50 milesUp to 100 milesUp to 200 milesUp to 500 miles500+ milesVehicle #2 Ownership*Owned by InsuredOwned by EmployeeVehicle #2 - Is there additional equipment for vehicle?* Yes No Vehicle #2 Loss Payee required?* Yes No Vehicle #2 Comprehensive Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #2 Collision Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #2 Rental Reimbursement*No Coverage$30 per day/30 days max$40 per day/30 days max$50 per day/30 days max$70 per day/30 days max$100 per day/30 days maxVehicle #2 Towing Reimbursement*No coverage$50$35$100VEHICLE #3 INFORMATIONVehicle #3 VIN number*Vehicle #3 Description*YearMakeModelGaraging Zip CodeVehicle #3 Description of vehicle use? Please provide details.*Does Vehicle #3 have an Anti -Theft Device?* Yes No Is Vehicle #3 used for deliveries or to pick up goods?* Yes No Vehicle #3 Usage*Business OnlyBusiness and PersonalVehicle#3 Average number of jobsites and errands per day?*Vehicle #3 average daily radius?*Up to 50 milesUp to 100 milesUp to 200 milesUp to 500 miles500+ milesVehicle #3 Ownership*Owned by InsuredOwned by EmployeeVehicle #3 - Is there additional equipment for vehicle?* Yes No Vehicle #3 Loss Payee required?* Yes No Vehicle #3 Comprehensive Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #3 Collision Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #3 Rental Reimbursement*No Coverage$30 per day/30 days max$40 per day/30 days max$50 per day/30 days max$70 per day/30 days max$100 per day/30 days maxVehicle #3 Towing Reimbursement*No Coverage$35$50$100VEHICLE #4 INFORMATIONVehicle #4 VIN number*Vehicle #4 Description*YearMakeModelGaraging Zip CodeVehicle #4 Description of vehicle use? Please provide details.*Does Vehicle #4 have an Anti -Theft Device?* Yes No Is Vehicle #4 used for deliveries or to pick up goods?* Yes No Vehicle #4 Usage*Business OnlyBusiness and PersonalVehicle#4 Average number of jobsites and errands per day?*Vehicle #4 average daily radius?*Up to 50 milesUp to 100 milesUp to 200 milesUp to 500 miles500+ milesVehicle #4 Ownership*Owned by InsuredOwned by EmployeeVehicle #4 - Is there additional equipment for vehicle?* Yes No Vehicle #4 Loss Payee required?* Yes No Vehicle #4 Comprehensive Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #4 Collision Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #4 Rental Reimbursement*No Coverage$30 per day/30 days max$40 per day/30 days max$50 per day/30 days max$70 per day/30 days max$100 per day/30 days maxVehicle #4 Towing Reimbursement*No Coverage$35$50$100VEHICLE #5 INFORMATIONVehicle #5 VIN number*Vehicle #5 Description*YearMakeModelGaraging Zip CodeVehicle #5 Description of vehicle use? Please provide details.*Does Vehicle #5 have an Anti -Theft Device?* Yes No Is Vehicle #5 used for deliveries or to pick up goods?* Yes No Vehicle #5 Usage*Business OnlyBusiness and PersonalVehicle#5 Average number of jobsites and errands per day?*Vehicle #5 average daily radius?*Up to 50 milesUp to 100 milesUp to 200 milesUp to 500 miles500+ milesVehicle #5 Ownership*Owned by InsuredOwned by EmployeeVehicle #5 - Is there additional equipment for vehicle?* Yes No Vehicle #5 Loss Payee required?* Yes No Vehicle #5 Comprehensive Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #5 Collision Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #5 Rental Reimbursement*No Coverage$30 per day/30 days max$40 per day/30 days max$50 per day/30 days max$70 per day/30 days max$100 per day/30 days maxVehicle #5 Towing Reimbursement*No Coverage$35$50$100VEHICLE #6 INFORMATIONVehicle #6 VIN number*Vehicle #6 Description*YearMakeModelGaraging Zip CodeVehicle #6 Description of vehicle use? Please provide details.*Does Vehicle #6 have an Anti -Theft Device?* Yes No Is Vehicle #6 used for deliveries or to pick up goods?* Yes No Vehicle #6 Usage*Business OnlyBusiness and PersonalVehicle#6 Average number of jobsites and errands per day?*Vehicle #6 average daily radius?*Up to 50 milesUp to 100 milesUp to 200 milesUp to 500 miles500+ milesVehicle #6 Ownership*Owned by InsuredOwned by EmployeeVehicle #6 - Is there additional equipment for vehicle?* Yes No Vehicle #6 Loss Payee required?* Yes No Vehicle #6 Comprehensive Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #6 Collision Deductible*No Coverage$250$500$1,000$2,000$3,000$5,000Vehicle #6 Rental Reimbursement*No Coverage$30 per day/30 days max$40 per day/30 days max$50 per day/30 days max$70 per day/30 days max$100 per day/30 days maxVehicle #6 Towing Reimbursement*No Coverage$35$50$100 DRIVER INFORMATIONNumber of Covered Drivers*1 Driver2 Drivers3 Drivers4 Drivers5 Drivers6 Drivers7 Drivers8 DriversDRIVER #1 INFORMATIONDriver #1 Name* First Last Driver #1 Date of Birth* MM slash DD slash YYYY Driver #1 License Number*Driver #1 License State*Date Driver #1 was added* MM slash DD slash YYYY Does Driver #1 have driving incidents on record?*yesnoDriver #1 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) DRIVER #2 INFORMATIONDriver #2 Name* First Last Driver #2 Date of Birth* MM slash DD slash YYYY Driver #2 License Number*Driver #2 License State*Date Driver #2 was added* MM slash DD slash YYYY Does Driver #2 have driving incidents on record?*yesnoDriver #2 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) DRIVER #3 INFORMATIONDriver #3 Name* First Last Driver #3 Date of Birth MM slash DD slash YYYY Driver #3 License Number*Driver #3 License State*Date Driver #3 was added* MM slash DD slash YYYY Does Driver #3 have driving incidents on record?*yesnoDriver #3 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) DRIVER #4 INFORMATIONDriver #4 Name* First Last Driver #4 Date of Birth* MM slash DD slash YYYY Driver #4 License Number*Driver #4 License State*Date Driver #4 was added* MM slash DD slash YYYY Does Driver #4 have driving incidents on record?*yesnoDriver #4 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) DRIVER #5 INFORMATIONDriver #5 Name* First Last Driver #5 Date of Birth* MM slash DD slash YYYY Driver #5 License Number*Driver #5 License State*Date Driver #5 was added* MM slash DD slash YYYY Does Driver #5 have driving incidents on record?*yesnoDriver #5 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) DRIVER #6 INFORMATIONDriver #6 Name* First Last Driver #6 Date of Birth* MM slash DD slash YYYY Driver #6 License Number*Driver #6 License State*Date Driver #6 was added* MM slash DD slash YYYY Does Driver #6 have driving incidents on record?*yesnoDriver #6 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) DRIVER #7 INFORMATIONDriver #7 Name* First Last Driver #7 Date of Birth* MM slash DD slash YYYY Driver #7 License Number*Driver #7 License State*Date Driver #7 was added* MM slash DD slash YYYY Does Driver #7 have driving incidents on record?*yesnoDriver #7 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) DRIVER #8 INFORMATIONDriver #8 Name* First Last Driver #8 Date of Birth* MM slash DD slash YYYY Driver #8 License Number*Driver #8 License State*Date Driver #8 was added* MM slash DD slash YYYY Does Driver #8 have driving incidents on record?*yesnoDriver #8 Incidents*SourceViolation DateDescriptionChargeable? (Yes-No) PAYMENT OPTIONSSelect payment choice:* Full Pay EFT 2 Pay EFT 4 Pay EFT 11 Pay Direct bill 2 Pay Direct bill 4 Pay Direct bill 10 Pay Carrier provides a direct bill system to provide flexibility when paying your premium. You may select to pay in full or EFT and receive an additional discount. There is a nominal fee with each installment. Once bound, you will have the option of paying the carrier with check or credit card (MasterCard, American Express or VISA).CAPTCHA
