West Coast Mexico Insurance - Mexico Car Insurance Online Application | Mexico Auto Insurance Online Application
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.

OWNER 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 ?:
WOULD YOU LIKE TO ADD ADDITIONAL DRIVERS ?:
Yes No
ENTER THE DATE YOU WANT TO COVERAGE 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:
Current Market Value: U.S. Dollars 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
Is there a lien-holder ?: Yes No
ARE YOU HAULING A BOAT ~ BOAT TRAILER ~ OTHER TRAILER ~ SPECIAL ACCESSORIES?:Yes  No
It is Mandatory to List ALL Towed Units and/or Accessories. ALL Towed Units are Only Covered When Powered Unit is Towing.
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

What is the result of 1+3 ?

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