Insurance Information Form
Please Write Neatly! Vehicle Information: Type: auto/truck/van/bus/moto/RV Year:______________________________ Make:_____________________________ Model:_____________________________ Value:$____________________________ Coverage Duration: Policy start date:_____________________ Policy start time:_____________________ Number of days in Mexico:____________ Driver Information: Name:_____________________________ Date of Birth:_______________________ Address:___________________________ City:_______________________________ State:____________Zip:_______________ Telephone:__________________________ Driver’s license #:___________________ State license was issued:_____________ Expiration:__________________________ Any drivers under 21?_________________ Will someone other than vehicle owner be driving vehicle while in Mexico? (circle one) YES / NO
Vehicle Registration Information: License plate:______________________ State registered:____________________ VIN:______________________________ Domestic Insurance Information: Insurance Company:_________________ Does this vehicle have full coverage in the United States? (please circle) Yes No Finance Company:___________________ Trailer/Shell/Camper Information: Year:______________________________ Make:_____________________________ Model:_____________________________ Length:_____________________________ ID Number:_________________________ State:______________________________ License Plate:_______________________ Value:$____________________________ Questions? Call Baja Bound toll-free at (888) 552-2252 or send an email to
[email protected].
If yes, are the older or younger than 21? (circle one) OLDER / YOUNGER *Attach to this form a photocopy of your driver's license
