Grupo54 All Purpose Application
Please submit this application for business and commercial property located in Mexico.
Proposed Effective Date
Name of Agent or Broker
Company  
E-mail
Website
Phone Number

    Fax

Insured Name in the US (if applicable)
Insured US Address

Street:
City:    State:    Zip:

Insured Name of Mexico Entity


 for more than one, please schedule on a separate form
Insured Address of Mexico Entity

Street:
City:    State:    Postal Code:

Value:

 Building: Contents: Equipment:
Flood Coverage: insuring: Buildings     Contents
Earthquake Coverage: insuring: Buildings     Contents
Occupancy and brief description of Mexico operation:
Construction Type:
Number of Stores:
Fire Protection Equipment: Extinguisher     Fire Hydrant     Sprinklers
Number of Units:
Current Insurer:                    Yearly Premium
Loss History (if available) last 3 years:
CGL Liability Limit:
Include Products?		 Burglary Theft Limit:
  Cash & Securities Limit:
EDP Computer Limit: Boiler & Machinery Limit:
Glass Coverage Limit: Loss of income Limit:

Automobile Fleet Information:  Vehicles are registered in USA     Mexico

Vehicle 1:

Year   Make  Model   Value

Vehicle 2: Year   Make  Model   Value
Vehicle 3: Year   Make  Model   Value
Vehicle 4: Year   Make  Model   Value

For additional vehicles, email a statement with year, make, model and value of each vehicle to customerservice@g54mexico.com
 

If you have additional buildings, please enter a statement of values or email a list to customerservice@g54mexico.com.

Statement of values for additional buildings: