Automobile Loss Notice

Automobile Loss Notice

Download Claim Info (PDF)

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 1 from the U.S./Canada or from Mexico.

Simply the Best

Simply the Best Mexican Auto Insurance Coverage, underwritten by Qualitas Compania de Seguros, S.A. de C.V., the company that insures more vehicles in Mexico than any other! Represented by Lewis and Lewis Insurance Agency, the Qualitas Agent and Broker that insures more Tourist Vehicles with Qualitas than any other.

Read a Customer's Testimonial!

"We have used Lewis and Lewis for the last two years. Lewis and Lewis come well recommended by people who have had an accident and actually used their service... They are courteous, easy to deal with, and reasonably priced."

Read more...

Price

Our prices are the lowest you'll find for such great coverage!

  • 30 day rates start at $79
  • 90 day rates start at $90
  • 180 day rates start at $105
  • Annual rates start at $129

Policies For You

A Tourist policy is Multiple Point Entry Mexican Auto Insurance Coverage for any Tourist possessing a valid driver's license. A Mexican National who is a permanent resident outside of Mexico with a Green Card is also considered a Tourist. Coverage is applicable only in the Republic of Mexico. For Mexican Nationalized or Permanently imported vehicles, please complete the online application for Mexican Registered Vehicle Insurance.

Customize Your Coverage

Excess Liability ~ Increases the insured Liability amount to $500,000 Combined Single Limit.

"Safe Trip" Towing ~ Adds Reimbursement, up to $240, for Emergency Road Service, Towing and Shipment of Parts.

Uninsured Motorist Plus ~ Increases the insured limit of Medical Payments to $20,000 per person; $100,000 per accident in the event that an uninsured or underinsured motorist causes you and/or your passengers bodily injury. If an uninsured motorist damages the insured vehicle, the collision deductible charged will be $0. The insured limit of Medical Payments is changed for the term of the policy to $20,000 per person; $100,000 per accident.

VIP Endorsement ~ Adds Vandalism, Increased Cost for a USA Repair, and Partial Theft coverage.

Watercraft Liability ~ Adds Liability of $300,000 CSL for watercraft not exceeding 28' while afloat or being launched.

Business Use ~ Allows the insured vehicle to be used for business.

2 Coverage Areas

Every Lewis and Lewis auto insurance policy provides you coverage throughout either the entire Republic of Mexico, which we call Plan B: Full Territory, or certain Mexican States, which we call Plan A: Limited Territory for coverage in Baja California Norte; Baja California Sur; Sonora; Chihuahua; Sinaloa; Durango; Coahuila; Nuevo Leon; and Tamaulipas.

View a map of our Full and Limited Territories

Car Insurance for Mexico