West Coast Mexico Insurance – Mexico Home Insurance Online Application | Mexican Home Insurance Online Application
Contact: Jason Wagner
Info@MexicoInsuranceExperts.com
office: 818-788-5353
www.MexicoInsuranceExperts.com
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.
FIRST NAME
LAST NAME
DATE OF BIRTH
OCCUPATION
ADDRESS IN USA or CANADA
CITY
U.S. STATE, CANADIAN PROVINCE or MEXICO STATE:
POSTAL CODE
PHONE # (1)
PHONE # (2)
PHONE # In Mexico
EMAIL
2ND EMAIL
HOW DID YOU HEAR ABOUT US OR FIND US? ?

HOW MUCH TIME OF THE YEAR ARE YOU SPENDING IN MEXICO?

PROPERTY USE? (SELECT ONE)

PRIMARY RESIDENCE   VACATION USE
DETAILS ABOUT THE OWNER/ENTITY WHO HOLDS TITLE ON THE INSURED LOCATION
INSURED NAME (This is the Registered Name on Your Mexican Deed or Fidiecomiso):        
ADDRESS:
CITY:
U.S. STATE, CANADIAN PROVINCE or MEXICO STATE:  
POSTAL CODE:
ADDITIONAL INTERESTS: MORTGAGEE (MG) AND/OR ADDITIONAL INSUREDS (AI)         YES NO
DETAILS ABOUT THE INSURED LOCATION
DWELLING TYPE REQUESTED EFFECTIVE DATE 12:01 AM
Mexico PHYSICAL ADDRESS (Include Lot&/or Unit#) DEVELOPMENT, COMMUNITY OR BUILDING NAME MEXICO CITY
MEXICO STATE MUNICIPALITY POSTAL CODE
MAIN STRUCTURE SQ. FT. (AIR CONDITIONED SPACE) LOT AREA Total SQ. FT. OTHER STRUCTURES (DETACHED FROM MAIN STRUCTURE)
YES NO  
ORIGINAL YEAR BUILT WHAT YEAR DID YOU TAKE POSSESION? # OF STORIES/LEVELS within HOME or CONDO?
OTHER Description of Other Structure: Square Feet: Provide Details about what Structures are Detached
from the Main Dwelling Structure?:
STRUCTURES
OTHER Description of Other Structure: Square Feet: Provide Details about what Structures are Detached
from the Main Dwelling Structure?:
STRUCTURES
OTHER Description of Other Structure: Square Feet: Provide Details about what Structures are Detached
from the Main Dwelling Structure?:
STRUCTURES
OTHER Description of Other Structure: Square Feet: Provide Details about what Structures are Detached
from the Main Dwelling Structure?:
STRUCTURES
HAVE YOU EVER UPDATED OR REMODELED YOUR HOME OR CONDO? YES NO
HAVE YOU EVER HAD INSURANCE PROTECTION ON THIS PROPERTY? YES NO
REQUESTED COVERAGES AND LIMITS OF LIABILITY
SECTION

COVERAGES

ENTER REQUESTED LIMITS OF COVERAGE
PROPERTY COVERAGES
 DWELLING VALUE
Replacement Cost 		Enter Limit: $ USD   
PERSONAL PROPERTY-REPL. COST
10% to 50% of Coverage A 		Enter Limit: $ USD
ADDITIONAL LIVING EXPENSE
Up to 20% of A or 40% of C 		INCLUDE EXCLUDE
LOSS OF RENTS
Up to 10% of A or 20% of C 		INCLUDE EXCLUDE
DEBRIS REMOVAL
Up to 10% of A or 20% of C 		Enter Limit: $ USD
LIABILITY PERSONAL LIABILITY IN MEXICO- LIMIT PER OCCURANCE
 $300,000  $500,000  $1,000,000  $2,000,000  
LIABILITY (MEDICAL) MEDICAL PAYMENTS IN MEXICO
 INCLUDED
CATASTROPHIC LOSSES
 EARTHQUAKE & VOLCANIC ERUPTION  
INCLUDE EXCLUDE
HURRICANE, WINDSTORM & HAILSTORM, FLOOD, TIDAL WAVES  
INCLUDE EXCLUDE
SCHEDULED VALUABLES
JEWELRY, SILVERWARE, ART & OTHER VALUABLE PROPERTY PER ATTACHED SCHEDULE
 YES NO
SOLAR EQUIPMENT DO YOU HAVE ANY SOLAR PANEL OR RELATED EQUIPMENT TO BE COVERED?
 YES NO  Enter Total: $
IMPORTANT INFORMATION ABOUT THIS INSURANCE
WHEN AN INSURANCE POLICY IS ISSUED, IT WILL BE BASED ON THE INFORMATION PROVIDED ON THIS APPLICATION. UNDER MEXICAN LAW, ANY MATERIAL MISREPRESENTATION OR CONCEALMENT WILL INVALIDATE THE INSURANCE. PLEASE BE ACCURATE.

SPACE FOR ADDITIONAL INFORMATION, COMMENTS OR NOTES:
UNDERWRITING INFORMATION – SELECT MOST APPROPRIATE BOX – ALL 15 ITEMS MUST BE COMPLETED
 
1. Structure Walls
 ONLY Masonry, Cement, Brick, Concrete or Steel Mostly Masonry, Cement, Brick, Concrete Mostly Frame Stucco Mostly Wood or other combustible material
1A. Structure Walls
2. Interior Walls & Ceilings
 ONLY Masonry, Cement, Brick or Concrete. Mostly Masonry, Cement, Brick or Concrete; with some wood, Frame Stucco or Plaster Mostly Frame Stucco or Plaster Mostly Wood or other similar combustible material
3. Exterior Roof
 Non Combustible: made of Masonry, Cement, Concrete, metal or Tile Fire Resistive Shake, Composition or any other guaranteed similar material. Other types, including Wood Shake, but NOT PALAPA type materials PALAPA or any similar type of highly combustible material
3A. Roof Type
4. Detached Structures
 NONE, or made ONLY of Masonry, Brick, Concrete or Metal walls AND non combustible roof Mostly made of Masonry, Brick, Concrete or Metal walls and fire resistive roof. Mostly Frame Stucco or Plaster walls with NO PALAPA roof or materials. Any Structure with a PALAPA roof or similar type of highly combustible materials.
4A. Detached Structures
5. Property Type
 Home, Condominium or Apartment within a Gated Building or Community Home, Condominium or Apartment within City Limits or within a Beach Resort Home, Condominium or Apartment outside City Limits but no more than 10 Miles from City Property located more than 10 Miles away from the closest City
5A. ARE THERE ANY STRUCTURES BETWEEN YOUR HOME/CONDO AND THE SEA-LEVEL LINE?
YES  NO
6. Owner Use and Rental Only Used by Owners & Guests. NOT Rented to Others Mostly used by Owners/Guests. Not Rented over 30 days per year Used by Owners, but rented to others 31 to 180 days per year Rented to Others for more than 180 days during the Year
7. Occupancy Vacancy Occupied at least 9 months during the year and never vacant for 30 consecutive days Occupied at least 6 months during the year and never vacant for 60 consecutive days Occupied at least 3 months during the year and never vacant for 90 consecutive days Occupied less than 3 months during the year or vacant for 90 or more consecutive days
8. Fire Detection Permanently Monitored Central or Police Station Fire Alarm System. Fire detection System with Smoke Detectors connected to Audible alarm No automatic Fire Alarm, but Smoke Detectors and Fire Extinguishers No Fire Alarm and/or No Smoke Detectors or No Fire Extinguishers
9. Security Permanently Monitored Security Alarm or 24 hour Security Guard Service Caretakers permanently living on premises or daily Security Patrol Service Audible Security Alarm or formal periodic (at least weekly) patrol service. No Security Alarm or formal Security Service.
9A. Security Does your Home or Condo have Bars on the Windows? Yes No
9B . Security Is the Home or Condo Located in a Gated Community? Yes No
9C . Security Does your Home or Condo have a Central Alarm System either Local or Monitored Yes No
10. Exterior
& Safe Protection		 Double Dead Bolt Locks for all doors AND Bars for all windows AND Bolted Security Safe. Two of Either: Double Dead Bolt Locks Doors, OR Bars on all Windows, OR Bolted Security Safe One of Either: Double Dead Bolt Locks Doors, OR Bars on all Windows, OR Bolted Security Safe NO Double Dead Bolt Locks and NO Bars on all Exterior Windows and Doors and NO Safe
11. Fire Department Fire Department located within 1 Mile from property Fire Department located between 1 and 5 Miles from Property Fire Department located over 5 but under 10 Miles from Property Closest Fire Department is more than 10 Miles away
12. Water Supply Readily available own additional water supply with pumping capability Nearby private or public water supply with pumping capability Public or private water supply, but no pumping capability No additional water supply and no pumping capability
13. Swimming Pool/SPA NONE; or fully fenced pool or spa, refurbished in last 5 years with no slides or spring boards Fully fenced Pools and/or spas over 5 years old with no slides and no spring boards. Pool-spa refurbhised in past 5 years, but is either not fenced, has slide or spring board Pool or Spas older than 5 years that are either not fenced or have slides or spring boards
14. Flood & Tidal Water Location is at least 10 miles away from any ocean waters, river beds, lakes or dams Location is between 1 and 10 miles away from any ocean waters, river beds, lakes or dams Located within 1 Mile from any such waters bodies but AT LEAST 300 Feet Above Water Level Located within 1 Mile from any such waters bodies but LESS THAN 300 Feet Above Water Level
14A. Distance from Body of Water In the Drop Down select the closest answer to the distance your property is located away from any body of water?
15. WEATHER & STORM SHUTTER PROTECTION Specifically Designed and Approved HVHZ Storm Shutters INSTALLED in ALL Exterior Openings of the Insured Structures No Storm Shutters, but WILL INSTALL Specifically Designed Approved HVHZ Storm Shutters in ALL Exterior Openings, when Required** Other Non-Approved Strom Protection, such as Wood Panels, Hurricane Glass, partial coverage or not Certified for HVHZ No Storm Shutters or storm protection is available and will NOT be installed
LOSS HISTORY IN THE LAST 5 YEARS?
HAVE YOU HAD ANY CLAIMS IN THE LAST 5 YEARS THAT HAVE BEEN FILED WITH YOUR INSURANCE COMPANY? YES  NO
UNDERWRITING QUESTIONNAIRE

1. I AM INTERESTED IN INTERNATIONAL LIFE INSURANCE TO SAFE GUARD MY FAMILY AND PAY OFF ANY OUTSTANDING LOAN ON MY PROPERTY:

Yes  No
2. I OWN VEHICLES IN MEXICO:

3. I AM INTERESTED IN TRAVEL HEALTH PROTECTION IN THE EVENT OF AN ACCIDENT OR ILLNESS WHILE I'M IN MEXICO FOR MYSELF AND OR MY FAMILY:

Yes  No

4. I LIVE IN MEXICO 6 MONTHS OF THE YEAR OR MORE AND I WOULD LIKE TO SEE OPTIONS FOR EXPAT MAJOR MEDICAL PROTECTION INCLUDING AIR EVACUATION:

Yes  No

5. I OWN OR PLAN ON PURCHASING A WATERCRAFT AND WOULD LIKE TO KNOW MORE ABOUT WATERCRAFT INSURANCE & LIABILITY IN MEXICO:

Yes  No

SPACE FOR ADDITIONAL INFORMATION, COMMENTS OR NOTES:
     Change Question