WEST COAST INSURANCE MEXICAN AUTOMOBILE APPLICATION
Contact: Jason Wagner
info@insuremewc.com
office: 818-788-5353
http://westcoastri.com
IMPORTANT NOTICE: This insurance will only apply in Mexico under the Mexican Legal System. No Coverage is afforded in neither the United States or Canada's legal system.

Complete Name of Primary Insured

First Name: Corporation Name: R.F.C. #
  Last Name: Driver's License #:
Address in
Mexico
Postal Code:
City:
State:
Address in U.S.
or Canada
Postal Code:
City:
State:

Date of Birth:
,
Phone Number:
E-Mail:
 Additional E-Mail:
How did you hear about Us or Find Us??:
Profession/Activity:
Type of Payment:
Currency:
 US. Dollars
Term:
 From , To ,

Additional Drivers

Full Name
 Driver's License #'s
 Date of Birth
,
E-Mail
Full Name
 Driver's License #'s
 Date of Birth
, 		E-Mail
Full Name
 Driver's License #'s
 Date of Birth
, 		E-Mail

 
 
DESCRIPTION OF THE VEHICLE
Please Check One Imported Car
Please Check One Personal Commercial
**** Please email a copy of your FM3 or Passport and also a copy of the current Auto Registration to Info@InsureBaja.com ****
Year Make Model
Plate # Trim Transmission
V.I.N. #    
State Drive Train Mileage
Equipment
This listed auto is in good mechanical condition.
Is the named Auto Currently Registered?: Yes No

Has this named auto ever been in any accident: Yes No

Does this named auto have a salvaged title?: Yes No
Clave Name of Agent Phone & Fax Number E-mail
WC West Coast Insurance Services 818-788-5353 / 818-206-4218 Info@InsureBaja.com
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