NON-RESIDENT PRIVATE AUTO LIABILITY CERTIFICATE OF INSURANCE
NO COVERAGE FOR PERSONS STUDYING OR WORKING IN THE UNITED STATE
Certificate Number
DECLARATION PAGE GEN 1186115
*ITEM ONE: APPLICANT INFORMATION WARNING THIS IS A TOURIST POLICY
NAMED INSURED and COMPLETE ADDRESS
THIS POLICY IS VALID ONLY FOR DRIVERS WHO PERMANENTLY RESIDE
MIGUEL ANGEL MENDEZ SERVIN
IN MEXICO, AND VISIT THE UNITED STATES OR CANADA FOR 28
RIO CHICO, 121, SAN MIGUEL CONSECUTIVE DAYS AT A TIME OR LESS. NO COVERAGE IS PROVIDED
GUANAJUATO 37000 LEON FOR PHYSICAL DAMAGE TO INSURED VEHICLE.
PHONE, AREA CODE
THIS CERTIFICATE FORMS PART OF MASTER POLICY NUMBER 7/711/94114/1
AGENT PRODUCER Agent Number
Policy Period ( 366 da OSCAR ADOLFO MARQUEZ LOZORNIO
From
7 7 5 9
6 / Febrero / 2024 Time 12:00 A.M. P.M.
To 6 / Febrero / 2025 Time 12:00 A.M. P.M.
12:01 A.M., S.T. at the address of the named insured or as state here in
*ITEM TWO: SCHEDULE OF COVERED AUTO INSURED (NO COVERAGE FOR COMMERCIAL USE VEHICLES).
COVERED LICENSE PLATE
AUTO
YEAR MAKE MODEL VIN & STATE
1 2004 TRAIL BLAZER TIPO A 4X2 LS L6 AUT 4P CA CE CD CB 1GNDT13S042216542 .
*ITEM THREE: SCHEDULE OF COVERAGE (NO COVERAGE PROVIDED IN MEXICO)
COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE
COVEREGES LIABILITY LIMITS OF LIABILITY PREMIUM
A. Bodily Injury $////////////// US dlls. per person $////////////// US dlls.
each accident
EXCLUDED
B. Property Damage $////////////// US dlls. each accident ///////////////////////////// EXCLUDED
C. Combined Single Limit $100,000.00 US dlls. each accident ///////////////////////////// INCLUDED
$5,000.00 US dlls. $25,000.00 US dlls.
INCLUDED
D. Medical Payments per person each accident
$200.00 US dlls.
INCLUDED
E. National Unity Assistence per event, 2 events per year
NATIONAL UNITY INSURANCE CO
ONE HUEBNER PARKE
15303 HUEBNER ROAD
SAN ANTONIO, TX. 78248 THIS CERTIFICATE OF INSURANCE WILL
BE INFORCE ONLY IF THE PREMIUM FOR
TO REPORT A CLAIM CALL / PARA REPORTAR UN ACCIDENTE:
DIRECTO: (512)861 099
THE CORRESPONDING MEXICAN AUTO
TOLL FREE: 1-866-329-6734 / POLICY IS PAID
LLAMADA DESDE MEXICO CON COSTO: 001 883 329 6734
or go to [Link]
ROAD SIDE ASSISTANCE/PARA ASISTENCIA VIAL:
TOLL FREE: 1-800-308-5513 / DESDE MEXICO 001-880-308-5513
IMPORTANT: Full Name of Applicant and Each Driver Required License Number Date of Birth Ocupation
FIRTS LAST
APPLICANT
XXXXXXXX XXXXXXXX XXXXXXX
DRIVER#2 Any driver with a valid driver license XXXXXXXX XXXXXXXX XXXXXXX
Certificate of Residency:It has been explained to me(us) that this National Unity Insurance Company policy is valid only when Mexican citizens or persons who reside full-time in
Mexico are operating the designated vehicle. I(we) have provided proof of my(our) Mexican residency to my(our) agent and certify that I am(we are) a full-time resident(s) of
Mexico. I(we) further understand that if it is determined that i am(we are) not, at any time during the policy period a full-time resident(s) of Mexico, this insurance is not valid a
does not provide any coverage to any person operating the designated vehicle in the United States of America or Canada.
Certificado de Residencia: Se me(nos) ha explicado que esta póliza de seguros de National Unity Insurance Company es válida solo cuando cuidadanos mexicanos o personas
que residen permanentemente en México están operando el vehículo designado. He(hemos) proporcionado a mi(nuestro) agente, prueba de mi(nuestra) residencia mexicana
y certifico que soy(somos) residente(s) permanente(s) de México. Entiendo(entendemos) además, que si se determina que no soy(somos) residente(s) permanente(s) de
México este seguro no será válido y no otorgará cobertura alguna a cualquier persona operando el vehículo designado en los Estados Unidos de Norteamérica ó Canadá.
Date Signature X
[Link]
NOTA: TRADUCCION DE CORTESIA Y CONDICIONES GENERALES DE POLIZA EN [Link]/[Link]
