| |
|
Fields are Mandatory
/ Fields are Not Mandatory |
|
| Option : |
Daily
6 Months(Multiple Entry)
12 Months(Multiple Entry)
|
| Effective Date : |
 |
| Expiration Date : |
|
Calculated Days : |
|
|
Entry Time : |
Central
Mountain
Arizona
Pacific |
|
|
Any drivers under 21 years? : |
No
Yes |
| Current
Residence : |
USA
Canada
Mexico
Other |
| Type
of Trip : |
Pleasure
Business |
| Carry
Collision/Theft on U.S. policy?: |
Yes
No |
| Coverage
in Mexico: |
Full=(Collision,
Total Theft, + Minimum Cov.)
Minimum=(Liability,
Medical Exp., Legal Assist.) |
| Select
Liability Limit: |
$50,000
$100,000
$300,000 |
| Select
Territory: |
All Mexico
Border States Only
(Baja N/S, Sonora, Sinaloa, Chih, Coah., NL,
Tamp. & Dgo) |
| Do
you want a Special Endorsement?: |
No
Yes (Increase
coverage, more information...) |
|
Is the
vehicle financed by GMAC? : |
No
Yes (If yes, fix deductibles &
set Liability=$100,000) |
|
Pulling Trailer or Carrying Other Units?: |
No
Yes (Show
additional fields for Trailer, Boat and Other Units) |
|
| Vehicle
Type: |
|
| Vehicle Value: |
|
|
Vehicle Special Equipment Value : |
|
|
Vehicle Special Equipment Description : |
|
|
Pre-existing Damage Description : |
|
