Mexican Auto Insurance

Quote Request Form

Tel: (415) 282-5888

for California Residents & International Tourists, Church Groups Welcome

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Please contact me to see if I am eligible for company hidden discounts!

This process does not bind coverage! Visit our tourist site turistqt.htm

Applicant Name ( Vehicle Owner or Applicant for Non-Owner Policy)
Mr. Mrs.  Miss Ms.

First Name:	Middle Name:	Last Name:	III, Jr.

 

E-mail Address:	Country/Nation:	County:

Telephone Numbers:

Home:	Work:	Fax: Back #

Address:

Street #	Street Name	Suite / PO #	City	State	Zip Code

Auto Value	Trailer Value	Boat Value
$	$	$

Will your Mexican trip be for commercial purposes? [Yes or No ] Commercial programs are available. Describe any commercial use:

Date Entering Mexico month / day / yyyy	# of Days in Mexico this Trip	# of Trips per Year	Total # of Days in Mexico next 12 Months
//

 Primary and Additional Driver Information:

Driver's Name: --First Name --Middle Name --Last Name	Sex/Gender: SR-22 SR-1P	Date of Birth: MM/DD/YYYY 07/04/1776	Marital Status: --Single --Married --Divorced --Widowed or --"D-Partner"	Occupation: --Military --Government or --Civilian: [specify job title]
1. First Driver (Primary)	Male Female SR-22 SR-1P	MM/DD/YYYY //	Marital Status: Select  Single  Married  Divorced  Widowed  D-Partner	Military Government Civilian: (specify)
2. Second Driver	Male Female SR-22 SR-1P	MM/DD/YYYY //	Marital Status: Select  Single  Married  Divorced  Widowed  D-Partner	Military Government Civilian: (specify)
3. Third Driver	Male Female SR-22 SR-1P	MM/DD/YYYY //	Marital Status: Select  Single  Married  Divorced  Widowed  D-Partner	Military Government Civilian: (specify)
4. Fourth Driver	Male Female SR-22 SR-1P	MM/DD/YYYY //	Marital Status: Select  Single  Married  Divorced  Widowed  D-Partner	Military Government Civilian: (specify)
5. Fifth Driver	Male Female SR-22 SR-1P	MM/DD/YYYY //	Marital Status: Select  Single  Married  Divorced  Widowed  D-Partner	Military Government Civilian: (specify)
6. Sixth Driver	Male Female SR-22 SR-1P	MM/DD/YYYY //	Marital Status: Select  Single  Married  Divorced  Widowed  D-Partner	Military Government Civilian: (specify)

Additional Driver Information for Discounts

Driver #	Driver Training	Years Driving Experience: Calif. US Foreign	Good Student	Non-Smoker	Student Away at School	Defensive Driver
1	Select  No  Yes		Select  No  Yes	Select  No  Yes	Select  No  Yes	Select  No  Yes
2	Select  No  Yes		Select  No  Yes	Select  No  Yes	Select  No  Yes	Select  No  Yes
3	Select  No  Yes		Select  No  Yes	Select  No  Yes	Select  No  Yes	Select  No  Yes
4	Select  No  Yes		Select  No  Yes	Select  No  Yes	Select  No  Yes	Select  No  Yes
5	Select  No  Yes		Select  No  Yes	Select  No  Yes	Select  No  Yes	Select  No  Yes
6	Select  No  Yes		Select  No  Yes	Select  No  Yes	Select  No  Yes	Select  No  Yes

Please list all violations and accidents (including not-at-fault accidents) for the last 3 years:

Violation CODE #	Accident Description & Violation Description	Violation Date & Conviction Date	Driver # Name
	Select ACCIDENT AT FAULT (AF) ACCIDENT NO BODILY INJURY (NBI) ACCIDENT NOT AT FAULT NO PROOF AVAILABLE (NAFNP) ACCIDENT NOT AT FAULT WILL PROVIDE PROOF (NAFWPP) Violation Description	MM/DD/YYYY // //
	Select ACCIDENT AT FAULT (AF) ACCIDENT NO BODILY INJURY (NBI) ACCIDENT NOT AT FAULT NO PROOF AVAILABLE (NAFNP) ACCIDENT NOT AT FAULT WILL PROVIDE PROOF (NAFWPP) Violation Description	MM/DD/YYYY // //
	Select ACCIDENT AT FAULT (AF) ACCIDENT NO BODILY INJURY (NBI) ACCIDENT NOT AT FAULT NO PROOF AVAILABLE (NAFNP) ACCIDENT NOT AT FAULT WILL PROVIDE PROOF (NAFWPP) Violation Description	MM/DD/YYYY // //
	Select ACCIDENT AT FAULT (AF) ACCIDENT NO BODILY INJURY (NBI) ACCIDENT NOT AT FAULT NO PROOF AVAILABLE (NAFNP) ACCIDENT NOT AT FAULT WILL PROVIDE PROOF (NAFWPP) Violation Description	MM/DD/YYYY // //
	Select ACCIDENT AT FAULT (AF) ACCIDENT NO BODILY INJURY (NBI) ACCIDENT NOT AT FAULT NO PROOF AVAILABLE (NAFNP) ACCIDENT NOT AT FAULT WILL PROVIDE PROOF (NAFWPP) Violation Description	MM/DD/YYYY // //
	Select ACCIDENT AT FAULT (AF) ACCIDENT NO BODILY INJURY (NBI) ACCIDENT NOT AT FAULT NO PROOF AVAILABLE (NAFNP) ACCIDENT NOT AT FAULT WILL PROVIDE PROOF (NAFWPP) Violation Description	MM/DD/YYYY // //
	Select ACCIDENT AT FAULT (AF) ACCIDENT NO BODILY INJURY (NBI) ACCIDENT NOT AT FAULT NO PROOF AVAILABLE (NAFNP) ACCIDENT NOT AT FAULT WILL PROVIDE PROOF (NAFWPP) Violation Description	MM/DD/YYYY // //

License Status by Driver Number:
 1               2               3              
Select ACTIVE LEARNER INTERNATIONAL SUSPENDED EXPIRED Select ACTIVE LEARNER INTERNATIONAL SUSPENDED EXPIRED Select ACTIVE LEARNER INTERNATIONAL SUSPENDED EXPIRED

 4               5               6              
Select ACTIVE LEARNER INTERNATIONAL SUSPENDED EXPIRED Select ACTIVE LEARNER INTERNATIONAL SUSPENDED EXPIRED Select ACTIVE LEARNER INTERNATIONAL SUSPENDED EXPIRED

Your comments about violations, accidents and convictions:

Vehicle(s) Description(s) -- Please Be Specific

Vehicle Use & Discounts

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Liability & Uninsured Motorists Coverage:

A. Liability Limit - Bodily Injury: [Required by Law] Select  $250,000 per person, $500,000 each accident  $100,000 per person, $300,000 each accident  $50,000 per person, $100,000 each accident  $25,000 per person, $50,000 each accident  $15,000 per person, $30,000 each accident 
B. Liability Limit - Property Damage: [Required by Law]                Select  $100,000 each accident  $50,000 each accident  $25,000 each accident  $10,000 each accident  $ 5,000 each accident 
C. UMBI--Uninsured/Underinsured Motorists Bodily Injury Limit:      Select  $250,000 per person, $500,000 each accident  $100,000 per person, $300,000 each accident  $50,000 per person, $100,000 each accident  $25,000 per person, $50,000 each accident  $15,000 per person, $30,000 each accident  None  (Not more than liability limit (A.) or company maximum.)
D. UMPD--Uninsured/Underinsured Motorists Property Damage:  Select  $3,500 each accident  Collision deductable waiver None 
E. MEDPAY--Medical Payment Limits-First Aid for You & Your Passengers: Select  $1,000 per person $2,000 per person $5,000 per person  $10,000 per person Maximum available 

List any additional insureds. State why they must be named, such as churches, rental, loan/lease companies, etc.

Do you currently have insurance? Yes No
Who is you current auto insurance company? 
When does your current policy expire?