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Date policy to go into force:*
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Applicant: First Name:
Last Name:
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Owner or Tenant? *
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Email Address: *
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Additional Insured:
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Other than Mexico - Street Address: *
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Other than Mexico - City: *
State: *
Zip: *
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Other than Mexico - Phone Number: *
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PROPERTY INFORMATION
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Address of property in Mexico - Street: *
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Mexico - City: *
State: *
Postal Code:
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Mexico - Phone Number: *
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Mortgagee (if any)
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Number of stories:
Use of residence:
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Type of residence:
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Walls of main building:
Other (describe):
* Note: Palapa construction needs special authorization from Seguros Comercial America.
Photographies of the property will be require with this application.
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Roof of main building:
Other: (describe)
* Note: Palapa construction needs special authorization from Seguros Comercial America.
Photographies of the property will be require with this application.
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Alarm:
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Is the property to a distance lesser than 500 meters (1/3 mile) from the sea or
lesser than 250 meters (1/6 mile) from a lake or a lagoon? **
** Note: This will need special authorization from Seguros Comercial America.
Photographies of the property and the distance to sea or lakes or lagoons need to be attached to the signed application.
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C O V E R A G E - Section I
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ALL RISK OF FIRE BUILDING: Insure?
----- Limit in U.S. Dollars: (including outbuildings)
Additional Coverage(s):
Hydrometeorological Phenomena for Building
Earthquake Building
Goods under express agreement for Hydrometeorlogical Phenomena
If yes, explain:
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C O V E R A G E - Section II
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ALL RISK OF FIRE CONTENTS: Insure?
----- Limit in U.S. Dollars:
Additional Coverage(s):
Hydrometeorological Phenomena for contents
Earthquake Contents
Debris removal ***
----- Limit in U.S. Dollars:
It is strongly recommended to contract this coverage. Debris removal applies for building and contents.
Suggested limit: 10% of limit of building and contents.
Extra expenses ***
----- Limit in U.S. Dollars:
The limit of this coverage has to represent the extra expenses expected to erogate in an annual basis.
Number of months to be indemnified:
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C O V E R A G E - Section III
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BURGLARY (Item 1):
------------ Limit in US Dollars:
For custom household goods as furniture, appliances, clothing, electronics and personel effects.
Also for artistic, sportive and electronic items or goods which cannot be easily replaced which value per unit
shall be equal or greater than $1,300 USD.
The Insurance Co. will request invoice, purchase receipt or photography.
BURGLARY (Item 2):
If yes, enter list of items:
Artistic, sportive and electronic goods or those goods of difficult replacement which unit or set value be
equal or greater than $1,300 USD. Also for artistic, sportive and electronic items or goods which cannot be
easily replaced which value per unit shall be equal or greater than $1,300 USD.
For example: paintings, rugs, porcelain, photographic, electronic, fishing, musical instruments, antiques.
In the event of burglary, the Insurance Co. will request invoice or purchase receipt and photography.
BURGLARY (Item 3):
If yes, enter list of items:
Jewelry, gold or silverware, weapons, watches, furs and precious stones which unit or set value be equal or
greater than $1,300 USD.
In the event of burglary, the Insurance Co. will request invoice or purchase receipt and photography.
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