Lorenz
Insurance Agency, Inc.
MEXICAN
AUTO INSURANCE SERVICES
P.O.
Box 1110, Calexico, CA 92232
760-357-3196
/ FAX 760-357-1592
Mexican
Auto Insurance Registration Form
Registered
Owner:____________________________________________________________________
Address:____________________________________________________________________________
City:_________________________________________ State:_________________ Zip:____________
Driver while in
Mexico:________________________________________________________________
Date entering
Mexico:___________________________ Time entering Mexico:___________________
Date departing
Mexico:__________________________ Time departing Mexico:__________________
VEHICLE INFORMATION
Year:____________________
Make:____________________ Model:___________________________
Vehicle Identification
No:______________________________________________________________
Collision/Fire/Total Theft
Insurance (Full Coverage): Yes_________________ No_________________
Blue Book
Value:$____________________________________________________________________
Will this vehicle be
pulling a trailer?: Yes_____________________________ No__________________
(If yes, please fill out the bottom portion)
Year:_________________
Make:____________________________ Model:______________________
Trailer Identification
No.:_______________________________________________________________
Collision/Fire/Total Theft
Insurance (Full Coverage): Yes_________________ No_________________
Blue Book Value:$____________________________________________________________________
**********************************************************************************
Charge to: _____VISA _____MasterCard _____American Express _____Discover Card
Credit Card
#:__________________________________________________________ Exp. Date:__________________________
Authorized name as it
appears on card:_______________________________________
Signature:__________________________