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 to (619)690-6533.

INSTANT MEXICO AUTO INSURANCE SERVICES

223 Via De San Ysidro San Ysidro, CA 92173                                                                        24-HOUR SERVICE
(619) 428-4714 TOLL FREE ALL U.S. & CANADA 800 345-4701
FAX SERVICE (619) 690-6533 YOUR POLICY FAX'D IN MINUTES.
APPLICATION FOR MEXICAN AUTO INSURANCE:                                             DATE:

NAME:                                   TEL NUMBER:
                                                                                                                                            Area Code  Phone Number
ADDRESS:   CITY: STATE: ZIP:

LIEN HOLDER:    ACCT #: FAX TO:
                             (If Applicable)                                                                                        Area Code  Phone Number
CLUB MEMBERSHIP:    I want to purchase a Mexican Auto Insurance Policy for: days.

Starting fromtoAt:Policies begin and end at same time.
     Example:  MM  DD  YYYY     MM   DD  YYYY

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 (optional)
Actual Cash Value of: (If full coverage desired)     PLAN 2, Liability - (PD,PL & Medical) Legal Services  ( Optional )

Vehicle:  $   Motorcycle:

$

  

Fishing Permit: 

 Month: Year: 
Trailer:  $   Vehicle Pulled by Motorhome:

$

  

Boat Permit:

 Month: Year:
Boat:  $   Other:

$

   Length:

WE ACCEPT THE FOLLOWING CREDIT CARDS VISA, MASTERCHARGE, AMERICAN EXPRESS, DISCOVER
Credit Card holder Name:     Credit Card Number:   Expiration Date:

     Credit Card Holder Authorized Signature: ____________________________________
NOTE: This application is for ordering purposes only.  No coverage is in effect until a policy number has been assigned.