Romero's Mexico Services

NOT A BINDER OF INSURANCE - APPLICATION ONLY FOR
Special Drivers License Policy for Tourists

Use This Application Only if  NOT  Planning to Tow a Vehicle or Trailer!

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

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

TERM OF INSURANCE - ANNUAL POLICY

DATE OF ENTRY INTO MEXICO:    //

ALL DRIVERS NAMES, DRIVERS LICENSE #'S AND DATE OF BIRTH's MUST BE LISTED. 
COVERAGE ONLY APPLIES TO THE NAMED DRIVERS.  THERE IS A 20% RATE SURCHARGE
IF ANY DRIVER IS UNDER 21 YEARS OF AGE. 

 

NAMED DRIVERS

 

  1. Last Name:  
         First Name:  
   License #:   State: 
   Date Of Birth: //(YYYY)
   Address:    
   City:  State:  Zip:

      
2. Last Name:  
    First Name:  
   License #:   State: 
   Date Of Birth: //(YYYY)
   Address:    
   City:  State:  Zip:


3. Last Name:  
    First Name:  
   License #:   State: 
   Date Of Birth: //(YYYY)
   Address:    
   City:  State:  Zip:


4. Last Name:  
    First Name:  
   License #:   State: 
   Date Of Birth: //(YYYY)
   Address:    
City:  State:  Zip:
EXCLUSION
Physical Damage Coverage (Risks 1&2)are not Available on this Policy.
COVERAGES:
LIABILITY
 
MEDICAL PAYMENTS
 
Liability $100,000
Combined Single Limit (CSL)
Bodily Injury and Property Damage
 
$4,000 per person
Maximum of $20,000 per occurrence

Current Auto Insurance Company:   
Policy Number: 
Expiration Date: