223 Via De San Ysidro,
San Ysidro,
CA 92173

(619) 428-4714

TOLL FREE ALL U.S. & CANADA
(800) 345-4701

FAX SERVICE (619) 690-6533
YOUR POLICY FAX’D IN MINUTES.

“Instant” Mexico Insurance Since 1973 we have been your ONE-STOP CENTER for all of your travel needs.

Have any questions?
Call us at (800) 345-4701
or (619) 428-4714

Fax a Mexican Insurance Policy - Instant Mexico Auto Insurance

INSTANT MEXICO AUTO INSURANCE SERVICES

To use our FAX A POLICY © simply fill out the following form. When completed print the form on your printer at 50% scale. Your form is now ready to be faxed with all of your information. Please fax it to (619) 690-6533.

Fax a Policy ©

APPLICATION FOR MEXICAN AUTO INSURANCE:

DATE:
TEL No:

NAME:
ADDRESS:
CITY:
STATE:
ZIP:

(If Applicable)
LIEN HOLDER:
ACCT #:
FAX TO:

CLUB MEMBERSHIP:

I want to purchase a Mexican Auto Insurance Policy for: days.

Starting from to
Example: MM DD YYYY MM DD YYYY

At:
Policies begin and end
at the same time.

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 Value of: (If full coverage desired)

PLAN 2, Liability - (PD,PL & Medical) Legal Services

Vehicle:
$

Motorcycle:
$

Trailer:
$

Vehicle Pulled
by Motorhome:
$

Boat:
$

Other:
$

WE ACCEPT THE FOLLOWING CREDIT CARDS VISA, MASTERCHARGE, AMERICAN EXPRESS, DISCOVER

Credit Card holder Name:
Company (If Company Card) :
Credit Card Number: ---
Expiration Date:

Credit Card Holder Authorized Signature:

Your FAX #

NOTE: This application is for ordering purposes only. No coverage is in effect until a policy number has been assigned.