California Surplus Line Insurance Broker License #0645420
2950 31st St., Suite 140 * Santa Monica, CA 90405-3093
Phone 310-399-0800 or 800-966-6830 - Fax 310-450-0700
Application for DAILY Tourist Mexican Auto Insurance
*Tourist policies are for MULTIPLE POINT ENTRY MEXICAN AUTO INSURANCE COVERAGE for any tourist (Non Mexican National)
possessing a valid drivers license including Mexican Nationals who are permanent residents outside of Mexico with a Green Card.
$300,000 Combined Single Limit Liability * $5,000 per Person / $25,000 per Accident Medical Payments * $75,000 Legal Service
Collision * Upset * Glass Breakage * Fire * Total Theft
● Deductibles: $500.00 except for $1,000 total theft.
● Coverage does not apply to Mexican Registered Vehicles.
● Labor Rates: $38.00 per hour for Body & Paint; $50.00
● Medical payments coverage is not available for Motorcycles, ATVs & Quads.
per hour for Mechanical & Frame.
● Coverage applies only in the Republic of Mexico.
1. POLICY EFFECTIVE DATE ______________________________ END DATE: ___________________________________________
2. PERSONAL DATA 3. FAX/EMAIL
Name ____________________________________Date of Birth (mm/dd/yyyy) __________________ Telephone (_____) ________ _________
Address __________________________________________City _____________________________ State _____ Zip ____________________
Driver’s License # _________________________________ State ______ Other Drivers* ___________________________________________
*Anyone with a valid drivers license, who is a non-Mexican National, may drive the vehicle whether they are listed here or not.
4. VEHICLE DATA
One Self-Propelled Vehicle per Policy. Motorcycles cannot be insured without another item of business insured. If you want Full Coverage, state the
current market value (up to $100,000 per unit) of your vehicle.