Mexican Auto Insurance Home Page

Automobile Loss Notice

Download Claim Info (PDF)

* indicates required fields

Step 1 — Insured Information
* Policy Number:
* Name and Address of Insured:
eMail:
Fax:
Home Phone:
Business Phone:
Step 2 - Contact Information
* Contact Name and Address:
* eMail:
Fax:
Home Phone:
Business Phone:
Step 3 - Loss Information
Location of Accident:
Authority Contacted:
Report Number:
Description of Accident:
(use separate sheet if necessary)
Step 4 - Insured Vehicle
Year:
Plate Number:
State:
Make:
Body Type:
Model:
V.I.N.:
Owner's Name and Address:
Driver's Name and Address:
(check if same as owner )
Relation to Insured:
(Employee, family, etc.)
Date of Birth:
Driver's License Number:
State:
Purpose of Use:
Used with Permission: Yes No
Describe Damage:
Estimate Amount:
Where Can Vehicle Be Seen:
When Can Vehicle Be Seen:
Step 5 - Other Vehicle/Property
Property Damaged: Describe Property: (if auto, year, make, model, plate#)
Other Vehicle/Property Insured: Yes No
Company or Agency Name:
Policy Number:
Owner's Name and Address:
Residence Phone:
Business Phone:
Other Driver's Name and Address:
(check if same as owner )
Residence Phone:
Business Phone:
Describe Damage:
Estimate Amount:
Where Can Damage be Seen:
Injured:
Name & Address Phone: (A/C, No) Extent of Injury
Witnesses or Passengers:
Name & Address: Phone: (A/C, No)
Remarks:
Reported by:
Adjuster Reported To:
Bank Name and Address:
Account Number:
ABA/Routing #:

 

Filling out this form is not the equivalent of contacting the Insurance Company which is a requirement as expressed in your contract of insurance. This form is only a tool to help speed up the claim process

If you have any further questions, please call (310) 207-7700 or (800) 966-6830.