Contact: Jason Wagner
Info@MexicoInsuranceExperts.com
office: 818-788-5353
www.MexicoInsuranceExperts.com
How did you hear about West Coast Insurance Services?
Requested Effective Date
From:
GENERAL INFORMATION:
Insured's First Name:   Insured's Last Name:  Date Of Birth:  ,   Marital Status :  
Address:
City :
State :
Postal Code :
 
Phone (Work):
Phone (Home):
Phone (Cell):
Fax:
Email:
Occupation:    Drivers License# :    State or Province:    Country Issued In: 

Will the insured be operating the boat: Yes No
Give details and nature of your boating experience including qualifications and details of previously owned vessels:

Have you or any person you have allowed or may allow to use your yacht, ever even charged with or convicted of any offence involving dishonesty or any other crimnal offence?:
Yes No
 
Have you had any accidents, claims or loses in connection with any vessel you have operated or owned under your control?:
Yes No (If Yes please provide full details, including dates of lose and amounts paid out)
Have you ever had insurance declined, non-renewed or cancelled :
Yes No (If Yes please provide full details)
Current Insurance Provider:
Renewal Date:
HULL INFORMATION:
Boat Name: Make: Model: Year Built:
Boat Type:     Length:   Beam :  Depth:  
Use of Boat:   Hull Construction Material:
Hull Serial #: Reconstruction Year if Any:
Date Purchased:     Purchase Price :  $ Current Hull Value:  $  
Has the Boat been Surveyed in the last 3 years?: Yes No (If Yes please provide the surveyor’s name and please eMail a copy of the survey to Submission@InsureMeBaja.com)
Have the Survey recommendations been complied with?: Yes No
Country of Origin: Flag:
Automated Fire Suppression System
Number of Crew members: Number of Allowed Passengers:
Navigation Zone: Mooring Location:
Is the Vessel subject to finance or mortgage?: Yes No (If Yes is selected open a field that says)
Loan Amount: Lender Name:
Motors/Engines: Inboard Motors Outboard Motors
H.P. :     Max Speed:  Fuel. :  
 
Inboard Motors are considered Part of the Hull Value, Please include Inboard Motors in the Hull Value Above.
Extra Passenger Boat: Yes No
Personal Effects (Fishing Equipment, Electronics, etc.) Yes No
Trailer Information: Yes No
Loss History: Any Claims in the last 3 Years? Yes No
SELECT OPTIONAL COVERAGES & LIMITS BELOW
 
AVAILABLE COVERAGES Yes      No REQUESTED LIMITS
 
   WATERCRAFT LIABILITY      
$ 100,000 $ 250,000 $ 500,000 $ 1,000,000 $ 2,000,000
 
   SKI LIABILITY      
$ 25,000   $ 50,000   $ 75,000   $ 100,000
 
   UNSURED BOATERS BODILY INJURY      
$ 25,000   $ 50,000   $ 75,000   $ 100,000
 
   HURRICANE COVERAGE       SAME LIMITS AS SECTION 1
 
   TSUNAMI & EARTHQUAKE       SAME LIMITS AS SECTION 1
 
WATERCRAFT INSURANCE OUTSIDE OF MEXICO Yes No
 
 
WATERCRAFT INSURANCE OUTSIDE OF MEXICO
 
COMPLETE NAMES RELATIONSHIP
TO OWNER
BIRTH DATE MARITAL
STATUS
SEX DRIVER LICENSE Drivers License Number STATE &
PROVINCE
Country License # Number of Minor and/or Major Violations # ACCIDENTS Boating Training YEARS BOATING
 
 
 
UNDERWRITING QUALIFICATION QUESTIONNAIRE
IF ANY ANSWER BELOW IS "Y", THIS APPLICATION REQUIRES FURTHER UNDERWRITING REVIEW FOR APPROVAL
 
IS THERE ANY OPERATOR: Y | N IS THE WATERCRAFT: Y | N
 
 
1. Under age of 18 or without a valid Driver License? | 6. Used or rented for commercial profit or for speed racing competition? |
 
2. With more than 1 major or more than 4 minor violations/accidents? | 7. Ever used for illegal activities or ever entered illegally into Mexico? |
 
3. Excluded under any auto or boat insurance policy? | 8. Older than 5 years, over 26 feet and not have a Navigation Certification? |
 
4. With a physical or mental disability or been in prison in past 5 years? | 9. Has ever been declined, excluded or cancelled from insurance? |
 
5. A resident of Cuba or North Korea? | 10. Owned by anyone with residence in Cuba or North Korea? |
 
SCHEDULE OF ADITIONAL INSUREDS OR LOSS PAYEES Yes No
 
 
FOR ANNUAL POLICIES ONLY : USE OF WATERCRAFT IN MEXICO
 
Total Days in Mexico:  Total Days Navigating:  Days Not Navigating: 
Days Not Navigating (Open Water):   Location: 
Days Not Navigating (Out of Water):     Location: 
 
  DESCRIBE SAFETY & CATASTROPHIC CONTINGENCY PLAN (In the Event of a Hurricane or Strong Tropical Storm What Will be Done to Protect your Vessel - Details Are Required)
  ADDITIONAL COMMENTS
  Do you employ a captain or caretaker ?
Does Insured have a safety & catastrophic contingency plan?  
 
THIS DOCUMENT REPRESENTS ONLY AN INSURANCE REQUEST, THEREFORE THIS DOES NOT REPRESENT ANY WARRANTY THAT IT WILL BE ACCEPTED BY THE INSURANCE COMPANY OR THAT IN CASE OF ACCEPTATION THIS WILL BE EXACTLY AS REQUESTED.
Clave Name of Agent Phone & Fax Number E-mail
WCRI West Coast Insurance Services 818-788-5353 / 818-206-4218 Info@MexicoInsuranceExperts.com
     Change Question

This is only a submission of your informal application. This application does not bind coverage for you or the Insured Item in which you are requesting information about.