West Coast Insurance Services - Mexico Auto Insurance Online Application | Mexico Car Insurance Online Application
Contact: Jason Wagner
info@insuremewc.com
office: 818-788-5353
http://westcoastri.com
IMPORTANT NOTICE: This form below is ONLY an Application to gather the details of the Auto/s you are requesting insurance for in Mexico. The insurance you are applying for will ONLY apply in Mexico under the Mexican Legal System. No Coverage is afforded in neither the United States or Canadian's legal system. All claims must be filed in Mexico before returning to the United States or coverage can be considered void. Please see general conditions for complete policy wording.

General Information
Name of Registered Owner: Best eMail:
Date of Birth: 2nd eMail:
Citizenship: Best Contact Phone # :
2nd Contact Phone #:
Driver's License Number:
State Or Province Licensed:
Years of Driving Experience: Address Vehicle is Registered to :
City:
Do you have a Valid Driver's License: Yes No State or Province
Any Major Convictions: Yes No Postal Code
Uncheck Box if mailing address is different from the vehicle registration address:
How did you hear about West Coast Insurance?:
How many Additinal Drivers would you like to Include on you policy?:
Please Note:Primary Driver and all additional drivers must be 21+ with a valid U.S/Canadian Driver's license . Please see general conditions for further details.
Enter the Date you Want Coverage to START:
 From: , To: ,
Choose 1 option: Please Check One
Option A: Includes Baja, Sonora, Sinaloa, Chihuahua, Durango, Coahuila, Nuevo Leon, & Tamaulipas (Limited Territory)
Option B: Includes the Entire Republic of Mexico (Full Territory)
How Many Vehicles ?:
All Vehicles,Scooters,Motocycles, E.T.C. must have current registration
Year: Make: Model:
V.I.N. #: Trim:
Plates #: State: Mileage:
Drive Train: Is your Auto currently registered: Yes No
Does this named automobile have a salvaged title: Yes No
Has this named automobile ever been in any accident: Yes No -
Does the vehicle have Auto Insurance in the U.S/Canada ?: Yes No
U.S/Canadian Carrier:
Policy Number:              
Exp/Renewal Date:      
Type of Coverage:        
Is there a lien-holder ?:
No Yes
Current Market Value: U.S. Dollars
BOAT / BOAT TRAILER / OTHER TRAILER / SPECIAL ACCESSORIES - It is mandatory to list all towed units and accessories in case is covered. All towed units are only covered when powered unit is towing. Yes  No
UNDERWRITING QUESTIONNAIRE
SPECIAL LINES UNDERWRITING QUESTIONS
1. Does the Applicant own and/or rent a Home/Condo in Mexico for 4+ months out of the year?
Yes No
2. Is the Applicant a Citizen of the USA/Canada, or Maintains Status of Permanent Resident in the USA or Canada?
Yes No
3. Does the Applicant maintain a Valid and Verifiable Drivers License in the USA or Canada?
Yes No
UNDERWRITING FOR UNACCEPTABLE VEHICLES
4. Is any vehicle registered in Mexico?
Yes No
5. Is any vehicle in poor mechanical condition or with extensive body or frame damage?
Yes No
6. Is any vehicle involved in speeding contests or organized racing?
Yes No
7. Is any vehicle participating in commercially organized caravans into Mexico?
Yes No
8. Is any vehicle used for instructional purpose or to carry people or property for a charge?
Yes No
9. Is any vehicle used or designed as an emergency response vehicle, ambulance, towing, or patrol?
Yes No
10. Is any vehicle used or designed as an All Terrain Vehicle or similar Off Road type vehicle?
Yes No

11. Is any vehicle of an experimental or prototype design or not registered for use upon public highways?
Yes No
12. Is any vehicle not owned by, leased to, or under a formal rental contract in the name of the Applicant?
Yes No
13. Do you have a Emergency Traveler's plan with Medical coverage and Air-Evacuation?
Yes No
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