Romero's Mexico Services
APPLICATION for Tourist/Auto/RV
NOT A BINDER OF INSURANCE

PLAN C: Limited  Territory - Daily Policy / Rates  W/ Tow

Have you purchased Insurance for Mexico in the last 12 months?  Yes No 

        If Yes, is your Mexico policy still in force?  Yes No

             Business use: YesNo                          Drivers under 21 years of age: YesNo
  If yes, 20% rate/options surcharge applies.          If yes, 20% rate/options surcharge applies.

DATE OF ENTRY INTO MEXICO:    //

  EFFECTIVE DATE OF POLICY:    //

 

PERSONAL DATA

 
 First Name: 

  Last Name: 
 Date of Birth:  /   (YYYY)  Telephone #: 

 Address:    City: 

 State:      Zip:      E-mail:

Driver's License #:    State:        Exp.Date:(MM/DD/YYYY) 

 OTHER DRIVER'S DATA:
     List all Other Driver(s) and Date(s) of Birth:
     Name:     D.O.B.: //(YYYY)
     Name:     D.O.B.: //(YYYY)
     Name:     D.O.B.: //(YYYY)
 

VEHICLE DATA Auto/RV

ONE SELF-PROPELLED VEHICLE PER POLICY. 
IF FULL COVERAGE IS DESIRED, A VALUE FOR EACH ITEM MUST BE STATED.  
Make:        Year:  (YYYY)        
  Model:    Current Value: $
 
  Is this Vehicle a Motorcycle or ATV?Yes No

   (If your vehicle is older than 20 years or is a Motorcycle or an ATV,
  coverage is LIMITED to liability only (Risks 3, 4 and 5).
Vehicle ID:    License #:    State: 
List your Current Auto Insurance Company                                   
    in the United States or Canada:
Policy Number:   Expiration Date: (MM/DD/YYYY)
      
   Lien Holder: 

       Address: 
If your Vehicle is a Pick-Up/Truck (total gross weight 1 TON or less),
      please Answer the Following: 
Shell/Sportsman Top:  Yes   No      Value: $
Camper Yes No     If yes, fill out information below:  
Year:  Make:   Model:   ID#: 
If your Vehicle is a Motor Home, please enter its Length in Feet:

 

OTHER TOWED UNITS

 
  
      
      All towed vehicles, trailers, boats and boat motors MUST be listed regardless
      of coverage. 

      Failure to list MAY VOID COVERAGE.  Do not enter a value unless full
      coverage is desired.

      Liability only coverage is included under the primary vehicle policy.

              

      Towed Vehicle: 

      Year:   Make:   Model:    ID#: 

      License Plate #:    State:     Value:   $ 

      
      

      Boat / Watercraft including Motors:

      Year:   Make:   Model:   ID#:  

      Length:   State:   Value:   $ 

      
      

      Boat / Watercraft Trailer: 

      Year:   Make:   Model:   ID#: 

      Length:   License Plate #:    State:    Value:   $ 

      

      Travel Trailer:

      Year:   Make:   Model:   ID#: 

       Length:   License Plate #:    State:    Value:   $ 

      

      Utility Trailer: 

      Year:   Make:   Model:   ID#: 

       Length:   License Plate #:    State:    Value:   $

OTHER UNITS

 
 ie. ATVs (Off Road), Motorcycles, Jet Skis:  
       These units available for liability only; medical and physical damageEXCLUDED.
 
Year:   Make:    Model:    Length:  
 ID#:  State: 
 

OTHER   VALUABLE   OPTIONS   AVAILABLE