Commercial Auto | Mercedes Insurance Brokerage

Commercial Auto Intake Form

FULL LEGAL BUSINESS NAME

DBA / TRADE NAME (IF DIFFERENT)

BUSINESS MAILING ADDRESS

CITY, STATE, ZIP

BUSINESS WEBSITE

DESCRIBE BUSINESS OPERATIONS, PRODUCTS/SERVICES, AND PRIMARY COMMERCIAL AUTO USE

VEHICLES 1-3: YEAR, MAKE, MODEL, VIN, GARAGING ADDRESS, RADIUS, AND USE

DRIVERS 1-3: NAME, DOB, LICENSE STATE/NUMBER, YEARS LICENSED, VIOLATIONS/ACCIDENTS, AND EXPERIENCE

CURRENT AUTO POLICY: CARRIER, POLICY NUMBER, EFFECTIVE DATES, LIMITS, AND RENEWAL DATE

CURRENT POLICY, DECLARATIONS, OR LOSS-RUN UPLOAD

Optional — you may submit without uploading.

Accepted file types: images and documents (PDF, JPG, etc.).

REQUIRED: DRIVER LICENSES for each driver listed — upload all drivers

Required for quoting — upload copies for every listed driver (multiple files allowed).

REQUIRED for quoting — upload copies for every listed driver (multiple files allowed).

REQUIRED: REGISTRATION CARDS for each vehicle listed — upload all vehicles

Required for quoting — upload registration cards for every listed vehicle (multiple files allowed).

PHONE

PRIMARY CONTACT LAST NAME