Mexico Registered Auto Insurance Online Application / Mexican Registered Car Insurance Online Application

Vehicles Registered in the United States & Canada do Not Qualify for this Application. Please Contact Us for more Information.
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: Corporation Name:
R.F.C. # Driver's License #:
Address in Mexico: Address in U.S. or Canada:
Postal Code: Postal Code:
City: City:
State: State:
Date of Birth:
Phone Number:
E-Mail: Additional E-Mail:
Country Of Residence: Country Of Citizenship:
How did you hear about Us or Find Us??:
Occupation:
Type of Payment:
Currency:
US. Dollars
Requested Start Date:
From

Additional Drivers

How Many additional drivers?:
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 ****
How Many Vehicles ?:
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

Current Market Value: U.S. Dollars

UNDERWRITING QUESTIONNAIRE
 
Yes All No All
1. Are all vehicles listed on this application registered in Mexico and have a Mexican License Plate?
Yes No
2. Have you held, over the last year any high ranking public or political position?
Yes No
3. Has your spouse, your parents or any of your children held any high ranking public or political position?
Yes No
4. Is any vehicle in poor mechanical condition or with extensive body or frame damage?
Yes No
5. Is any vehicle involved in speeding contests or organized racing?
Yes No
6. Is any vehicle used for instructional purpose or to carry people or property for a charge?
Yes No
7. Is any vehicle used or designed as an emergency response vehicle, ambulance, towing or patrol?
Yes No
8. Is any vehicle used or designed as an All Terrain Vehicle or similar Off Road type vehicle?
Yes No
9. Is any vehicle of an experimental or prototype design or not registered for use on public highways?
Yes No
10. Is any vehicle not owned by, leased to, or under a formal rental contract in the name of the Applicant?
Yes No

What is the result of 1+3 ?

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