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"> 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 1 2 3 4 5 6 7 8 9 10 11 12 : 00 30 A.M. P.M. 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.
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 1 2 3 4 5 6 7 8 9 10 11 12 : 00 30 A.M. P.M. Policies begin and end at same time. Example: MM DD YYYY MM DD YYYY
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 )
$
Fishing Permit:
Boat Permit:
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.