INSTANT MEXICO AUTO INSURANCE SERVICES

To use our FAX A POLICY © simply fill out the following form. When completed print the form on your printer. Your form is now ready to be faxed with all of your information. Please fax it to (619) 690-6533.

Fax a Policy ©

APPLICATION FOR MEXICAN AUTO INSURANCE:
DATE:
TEL No:
NAME:
ADDRESS:
(If Applicable)
LIEN HOLDER:
ACCT #:
FAX TO:
CITY:
STATE:
ZIP:

CLUB MEMBERSHIP:

I want to purchase a Mexican Auto Insurance Policy for: days.

Starting from to
Example:       MM  DD  YYYY                            MM   DD  YYYY
At:
Policies begin and end
at the same time.
Vehicle
Year

Make

Model

Vehicle ID No.
Trailer
Year

Make

Model

Vehicle ID No.
Boat   
Year

Make

Model

Vehicle ID No.
Vehicle Pulled by Motorhome
Year

Make

Model

Vehicle ID No.
COVERAGE PLAN: Please mark the plan:

PLAN 1, Collision Fire & theft Liability - (PD,PL & Medical) Legal Services
Actual Cash Value of: (If full coverage desired)

PLAN 2, Liability - (PD,PL & Medical) Legal Services

Vehicle:
$
Motorcycle:
$
Trailer:
$
Vehicle Pulled
by Motorhome:
$
Boat:
$
Other:
$
WE ACCEPT THE FOLLOWING CREDIT CARDS VISA, MASTERCHARGE, AMERICAN EXPRESS, DISCOVER

Credit Card holder Name:
Company (If Company Card) :
Credit Card Number: ---
Expiration Date:

Credit Card Holder Authorized Signature:
Your FAX #

NOTE: This application is for ordering purposes only.  No coverage is in effect until a policy number has been assigned.