Romero's Mexico Services

 Watercraft Insurance Application

NOT A BINDER OF INSURANCE

Have you purchased Insurance for Mexico in the last 12 months?YesNo

If Yes, is the Mexico Insurance policy you purchased in the last 12 months still in force? Yes    No


Date of Entry into Mexican Water: //
Term:     
PERSONAL DATA 
Last Name of Owner/Name Insured:   
First Name of Owner/Name Insured:  

Driver's Lic.#:        State: 
Address:   
City:      
State:         Zip: 
Occupation:
Home Phone:
Bus. Phone:

Email:
LIABILITY AND MEDICAL COVERAGE LIMITS 
SELECT THE COVERAGE THAT BEST FITS YOUR NEEDS:
Liability (P&I) limit:$20,000  $50,000 $100,000
                      $300,000 $500,000 
Medical Payments (per person):$5,000 $10,000 
Number of persons to be covered:
WATERCRAFT DESCRIPTION & EQUIPMENT 
Name/Make of Watercraft: 
D.O.C./I.D. Number:
Model: Sail Cruiser Runabout Other:   
Year:   Length(In Feet):   Construction: 

Equipment: Fixed CO2 RDF Radar Radio Auto Pilot
           Fath GPS Furniture Tackle Apparel
           Other: 
Auxiliary Power: Diesel  Gas  Sail 

Number of Motor(s): 1 2 3    
Make of Motor(s):  Year:  HP: 
Tender(Dingy): 
   Year:  Length(In Feet):  HP: 

Trailer: 
   Year:  Length(In Feet): 
   ID #: 
VALUES (U.S. Dollars)  
       All Policies will include Legal
Watercraft:           Broker and policy fees.

Equipment:                  Coverages for Liability and Medical
Motor(s):                     Payment only do not require Values
Tender:                     or listing of equipment.

Trailer:             

NAVIGATIONAL AREA:
This policy is in effect only when the insured watercraft is in use in the
territorial waters of the Republic of Mexico including inland lakes and 
rivers and the insured hereby warrants that the described/insured 
watercraft will not be navigated, docked or stored in Mexican territorial  
waters,including the Sea of Cortez, south of 24 degrees north latitude 
between June 1 and November 1 (Except by written endorsement and the 
payment of a 25% surcharge.)
If you will be south of 24 degrees north latitude between June 1
and November 1, please select "Yes" for Endorsement.
Seasonal Endorsement(June 1 to November 1): Yes No
Mooring Location in Mexico:  
Current Insurance Company:   
Expiration Date:  (MM/DD/YY)
Prior Watercraft Experience: 
Previous Losses:             
Charter Use? (Use of watercraft by person(s)/passenger(s) for hire) 

YesNo  If "yes" explain: 
Commercial Use? (Used for transportation of equipment, goods, cargo, etc.) 
YesNo  If "yes" explain:

VALID ONLY WITHIN THE REPUBLIC OF MEXICO