West Coast Global Insurance - Mexican Boat & Yacht Insurance Application - Mexico Boat & Yacht Insurance Application
Contact: Jason Wagner
Info@MexicoInsuranceExperts.com
office: 818-788-5353
www.MexicoInsuranceExperts.com
First Name
Last Name
ADDRESS
CITY
STATE
ZIP CODE
COUNTRY
EMAIL
PHONE
FAX
How did you hear about Us or Find Us?
1. GENERAL INFORMATION:
Owner's Name:
Date of Birth: ,
Type:
Occupation:

If the address is the same, please click here
Address:
City
State
Zip Code
 
Mexico Address:
City:
State:
Zip Code:
Requested Start Date
From:
2. HULL INFORMATION:
Boat Name:
Make: Model: Year Built:
Year Last Survey: Reconstruction Year:
Max Speed: Hull Construction Material:
Boat Type:
Boat Size:
Beam Depth
Hull Serial #:
Hull Value: $
Use of Boat:
Date Purchased:
Purchase Price :
Boating Exprience(Details of length and nature of your boating exprience including qualification and details of previously owned vessels) :
Country of Origin: Port of Registration: Flag:
Automated Fire Suppression System
Number of Crew members: Number of Passengers:
Navigation Zone:
Motors/Engines: Inboard Motors Outboard Motors
H.P. :    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
 
 
  Choose Number of Additional Watercraft Operators (All Information must be Completed as per Underwriting Requirements)
 
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?  
 
Clave Name of Agent Phone & Fax Number E-mail
WCRI West Coast Global Insurance 818-788-5353 / 818-206-4218 Info@MexicoInsuranceExperts.com
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.
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Applicant's Statement
I have read the above application and any attachments. I declare that the information I provided is true, complete and correct to the best of my knowledge & belief. This information is being offered to the company as an inducement to issue the policy for which I am applying and no coverage is offered at this time.

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.