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


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

City:    State:    Zip:

Insured Name of Mexico Entity

 for more than one, please schedule on a separate form

Insured Address of Mexico Entity

City:    State:    Postal Code:


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

If you have additional buildings, please enter a statement of values or email a list to

Statement of values for additional buildings: