WEST COAST INSURANCE APPLICATION FOR CONDO INSURANCE IN MEXICO

Contact: Jason Wagner
info@insuremewc.com
office: 818-788-5353
westcoastri.com

IMPORTANT NOTICE: This insurance will only apply in Mexico under the Mexican Legal System. No Coverage is afforded in neither the United States or Canada's legal system.

NAME OF APPLICANT
ADDRESS IN USA or CANADA
CITY
STATE
POSTAL CODE

TELEPHONE IN USA
TELEPHONE IN MEXICO
FAX
EMAIL
2ND EMAIL
How did you hear about Us or Find Us??

INFORMATION ABOUT THE LOCATION IN MEXICO

CONDO TYPE:

STAND ALONE CONDO

TOWNHOME

CONDOMINIUM

APARTMENT

OTHER Describe:

EXACT STREET ADDRESS

(INCLUDE LOT #)

CITY

STATE

MUNICIPALITY

MX POSTAL CODE

ORIGINAL
YEAR BUILT

HOW MANY
YEARS OWNED

# OF STORIES

ENTER TOTAL

MAIN STRUCTURE

Size Sq. Ft.

OTHER STRUCTURES: any Detached Structures such as Detached Garage, Surrounding Walls, Pools, etc.

Total Size Sq. Ft.

LOT AREA

Total Sq. Ft.

ENTER YEAR OF LATEST UPDATE
OR RENOVATION, IF ANY, FOR:

ROOF

PLUMBING

HEATING

WIRING

EXTERIOR

INTERIOR

CURRENT INSURANCE:

Insurance Company	Policy Number	Expiration Date	Annual Premium	Ever Cancelled by Co?	Ever NonRenewed?

REQUESTED POLICY PERIOD

From	To	12:01 AM
,	,	12:01 AM

REQUESTED COVERAGES AND LIMITS OF LIABILITY

Section	Coverages	Check Coverage Type and Enter Values as applicable		MINIMUM DEDUCTIBLES
Section	(Check Requested Items below)	Condo Owners	Apartment/Condo	Per Loss/Event
I: Property Coverages	A: Dwelling Value Replacement Cost	Enter Limit: $	NOT COVERED	Theft:
	B: Other Structures Up to 10% of Coverage A	Enter Limit: $	NOT COVERED	All Other Perils: $500.-
	C: Personal Property-Repl. Cost 10% to 50% of Coverage A	Enter Limit: $	Enter Limit: $	Loss of Use: 3 Days Waiting Period
	D1: Additional Living Expense Up to 20% of A or 40% of C	Enter Limit: $	Enter Limit: $	Loss of Use: 3 Days Waiting Period
	D2: Loss of Rents –Annual Rental Up to 20% of A or 40% of C	Enter Limit: $	Enter Limit: $	Loss of Rents: $1,000.-
II: Liability	Debris Removal Up to 10% of A or 20% of C	Enter Limit: $	Enter Limit: $	NO DEDUCTIBLES for Section II
	E: Personal Liability in Mexico	$250,000	$100,000
	Limit Per Occurence	$500,000	$250,000
	Check Selected Limit	$1,000,000	$500,000
	F: Medical Payments in Mexico	$1,000 per Person	$1,000 per Person
III: Catastrophic Losses	G: Earthquake & Volcanic Eruption	Combined Sum of all the limits for the selected Section I Coverages above and Section IV Coverages Below	Combined Sum of all the limits for the selected Section I Coverages above and Section IV Coverages below	2% of Combined Limit, PLUS 20% of each Loss
III: Catastrophic Losses	H-I-J: Hurricane, Windstorm & Hailstorm, Flood, Tidal Waves			2% of Combined Limit, PLUS 20% of each Loss
IV: Scheduled Valuables	K–N: Jewelry, Silverware, Art & Other Valuable Property per attached schedule	Enter Total: $	Enter Total: $	Per Schedule
V: Condo Services	O–R: Plumbing, Locksmith, Plate Glass & Other Services	$100.- per event	$50.- per event	NONE

ADDITIONAL INTERESTS: MORTGAGEE (MG) AND/OR ADDITIONAL INSUREDS (AI)/INTERESES PREFERENTES

NAME

LOAN #

ADDRESS

CITY

STATE

ZIP

NAME

ADDRESS

CITY

STATE

ZIP

NAME

ADDRESS

CITY

STATE

ZIP

THE INFORMATION PROVIDED ABOVE MUST BE ACCURATE AND COMPLETE, BUT THIS APPLICATION FOR INSURANCE MAY NOT BE PROCESSED UNLESS IT IS ATTACHED TO A FULLY COMPLETED AND SIGNED PAGE 2 OF THIS FORM AND ANY OTHER REQUIRED SUPPORTING REPORTS AND/OR SCHEDULES.

IMPORTANT INFORMATION ABOUT THIS INSURANCE

WHEN AN INSURANCE POLICY IS ISSUED, IT WILL BE BASED ON THE INFORMATION PROVIDED ON THIS APPLICATION. UNDER MEXICAN LAW, ANY MATERIAL MISREPRESENTATION OR CONCEALMENT WILL INVALIDATE THE INSURANCE. PLEASE BE ACCURATE.

UNDERWRITING INFORMATION – SELECT MOST APPROPRIATE BOX – ALL 15 ITEMS MUST BE COMPLETED

	1. Structure Walls	ONLY Masonry, Cement, Brick, Concrete or Steel	Predominantly Masonry, Cement, Brick, Concrete	Predominantly Frame Stucco	Predominantly Wood or other combustible material
	2. Interior Walls & Ceilings	ONLY Masonry, Cement, Brick or Concrete.	Mostly Masonry, Cement, Brick or Concrete; with some wood, Frame Stucco or Plaster	Predominantly Frame Stucco or Plaster	Predominantly Wood or other similar combustible material
	3. Roof	Non Combustible: made of Masonry, Cement, Concrete, metal or Tile	Fire Resistive Shake, Composition or any other guaranteed similar material.	Other types, including Wood Shake, but NOT PALAPA type materials	Other types, including Wood Shake, but NOT PALAPA type materials
	4. Detached Structures	NONE, or made ONLY of Masonry, Cement, Brick, Concrete or Metal walls and non combustible roof	Predominantly made of Masonry, Cement, Brick, Concrete or Metal walls and fire resistive roof.	Predominantly Frame Stucco or Plaster walls with NO PALAPA roof or materials.	Any Structure with a PALAPA roof or similar type of highly combustible materials.
	5. Property Type	Condo, Condominium or Apartment within a Gated Building or Community	Condo, Condominium or Apartment within City Limits or within a Beach Resort	Condo, Condominium or Apartment no more than 10 Miles outside of City Limits	Property located more than 10 Miles away from the closest City
	6. Owner Use and Rental	Only Used by Owners & Guests. NOT Rented to Others	Mostly used by Owners/Guests. Not Rented over 30 days per year	Used by Owners, but rented to others 31 to 180 days per year	Rented to Others for more than 180 days during the Year
	7. Occupancy Vacancy	Occupied at least 9 months during the year and never vacant for 30 consecutive days	Occupied at least 6 months during the year and never vacant for 60 consecutive days	Occupied at least 3 months during the year and never vacant for 90 consecutive days	Occupied less than 3 months during the year or vacant for 90 or more consecutive days
	8. Fire Detection	Permanently Monitored Central or Police Station Fire Alarm System.	Fire detection System with Smoke Detectors connected to Audible alarm	No automatic Fire Alarm, but Smoke Detectors and Fire Extinguishers	No Fire Alarm and/or No Smoke Detectors or No Fire Extinguishers
	9. Security	Permanently Monitored Security Alarm or 24 hour Security Guard Service	Caretakers permanently living on premises or daily Security Patrol Service	Audible Security Alarm or formal periodic (at least weekly) patrol service.	No Security Alarm or formal Security Service.
	10. Exterior & Safe Protection	Double Dead Bolt Locks for doors AND Bars for all windows AND bolted Security Safe	Two of Either: Double Dead Bolt Locks Doors, OR Bars on all Windows, OR Bolted Security Safe	One of Either: Double Dead Bolt Locks Doors, OR Bars on all Windows, OR Bolted Security Safe	No Double Dead Bolt Locks and No Bars on all Exterior Windows and Doors; and/or No Safe
	11. Water Supply	Readily available own additional water supply with pumping capability	Nearby private or public water supply with pumping capability	Public or private water supply, but no pumping capability	No additional water supply and no pumping capability
	12. Fire Department	Fire Department located within 1 Mile From property	Fire Department located between 1 and 5 Miles From Property	Fire Department located over 5 but under 10 Miles From Property	Closest Fire Department is more than 10 Miles Away
	13. Swimming Pool/SPA	NONE; or fully fenced pool or spa, refurbished in last 5 years with no slides or diving boards	Fully fenced Pools and/or spas over 5 years old with no slides and no diving boards	Pool-spa refurbished in past 5 years, but is either not fenced, has slide or diving board	Pool or Spas older than 5 years that are either not fenced or have slides or diving boards
	14. Flood & Tidal Water	Distance from any Ocean Waters, river beds, lakes or dams: (Please be as specific as possible) Miles Feet Yards
	15. Weather	Professionally installed Permanent Storm Shutters for all windows and exterior openings	Professionally made and ready to install Storm Shutters for all windows and exterior openings	Wood Panels pre-made by owner and available to cover all exterior openings	No Storm Shutters or readily available storm protection for all exterior openings
SUPPORTING DOCUMENTS		VALUABLE PROPERTY SCHEDULE Required for Section IV Coverages	SELF-INSPECTION REPORT Required for Condos over $500,000	PHOTOGRAPHIC REPORT Required for Condos over $500,000	OTHER (Describe)

UNDERWRITING QUESTIONNAIRE
1. Do you have any Autos in Mexico?	Yes No
Make Model Year Mileage Registration in USA/Canada/Mexico
2. Do you currently have auto insurance in Mexico?	Yes No
Renewal Date:
3. How much time of the year are you traveling out of your Condo country?
4. Are your Trip Durations out of your Condo Country More or less then 30 days at one time?

NOTES: Limitations & or no coverage is applied to those Condos that have exposures such as (Palapa or Thath Roofs). We do have markets for these exposures but it is important that we are aware of this prior to submitting your application to Underwriting.

LOSS HISTORY – LIST ALL KNOWN LOSSES OVER THE PAST 5 YEARS (If NO LOSSES write NONE below)

DATE	DESCRIPTION	INSURANCE COMPANY	POLICY NUMBER	AMOUNT PAID

Space for Additional Information, Comments or Notes:

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Checking this box serves as my digital signature I understand the above is a submission of my informal application. This application does not provide coverage for me or the insured item in which I am requesting information about. The questions answered with requests for quoting coverage may change once a formal quote is generated from an insurance company. I understand that West Coast Real Estate & Insurance, Inc. does not guarantee any coverages and has offered this informal application as a way to collect general information. I have read the above application and any attachments. I declare that the information I provided is true, complete and correct to the best of my knowledge & belief. This information is being offered to the company as an inducement to issue the policy for which I am applying and no coverage is offered at this time.