Please provide the following contact information: First name Last Name Garage address City, State & Zip Home Phone Work Phone Cell phone Email   TRAVEL INFORMATION:     Date entering Mexico: Date Leaving Mexico: Territory: VEHICLE:     Year: Make: Model: Value: Liability Only?: Select Yes No We suggest using the Kelly Blue Book or NADA guide to determine your vehicle's current value. In the event of a total loss, the claim settlement will not exceed the current market value of the vehicle. COVERAGES: Many lenders, including GMAC, require you to carry at least $100,000 Liability Limit, and also require the Fixed Deductibles option. Liability Limit: Physical Damage Deductibles: TOWED UNITS: Are you towing anything? If not, then leave this section blank: Select Yes No How many units are you towing?  What is the total value of the units you are towing? (Not applicable for commercial trailers) IMPORTANT: After you receive your quote, you must list all Towed/Trailered Units on the application page.  Units not listed could  void the entire policy coverage. Towed units include: 5th wheel trailers, camper trailers, boats, utility trailers, towed trailers, towed vehicles, etc. Each towed unit my be listed separately, ie. boat and trailer should be listed as two units. . OTHER INFORMATION: Are you retired in Mexico, or is your vehicle in Mexico more than 180 days per year? Select Yes No Do you use the vehicle for business in Mexico, or to drive to and from work or school in Mexico? Select Yes No Will there be any drivers under 21 on this policy? Select Yes No Do you carry collision and theft coverage on your US/Canadian policy? Select Yes No How did you hear about us?  Your email address:                       .   Privacy Policy/User agreement   Copyright 2006 Amtex Insurance Company. All rights reserve