West Coast Insurance Services ~ Mexico Affiliate Signup
(818) 788-5353
westcoastri.com
Contact: Pauline Poncy
Pauline@WestCoastRi.com
Direct Mex: 52 1 (624) 171 1282
Direct US: (541) 601-5487
westcoastri.com
AFFILIATE SIGNUP
Are you a Licensed Insurance Agent?
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What is your Insurance License Number ?
Are you a Licensed P&C Agent ?
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Are you a Licensed Life & Health Agent?
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What States are you Licensed in ?
Do you currently have E&O Insurance in Place ?
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How did you hear about us?:
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If you have sold Mexico Insurance in the Past or Sell Mexico Insurance now, what carriers do you represent?:
Tax ID Number:
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Products you are interested in working with?
Mexico Homeowners Insurance & Mexico Condominium Insurance:
Mexico Tourist Auto Insurance:
Mexico Watercraft Insurance:
Additional Comment(s):
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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.