Everitt Boles Motorsport Insurance Management

On Track Claims - Notification

General - please read this section first

ACCIDENT STATEMENT
It is necessary that you obtain an independent statement from a circuit official confirming the location, date and time of the accident. Please click on the 'Accident Statement' link to print a version of this form in either MS Word or PDF format.
THIS FORM
Complete and submit this form no later than 48 hours after the date of the incident.
INFORMATION
Answer EVERY question. If you cannot supply all information now, provide an explanation at the bottom of this form.
PHOTOGRAPHS
These MUST be taken prior to dismantling. If you do not do this, your claim will NOT be paid!
CLAIMS PROCEDURE
For full Claims Procedure please click on the 'Procedure' link.

The Event
Date of Accident:	click on calendar to choose date
Time of Accident:
Circuit:
Name of Corner on Circuit:
Was the driver hurt? Yes No
Did the driver receive medical attention? Yes No
Is the driver likely to be able to race within the next fourteen days? Yes No
Was the accident during:
Weather Conditions/Track Surface:
Description of accident:
Full details of accident:

Inspection Address
Please advise us of the current whereabouts of this vehicle in case we wish to carry out an inspection:

If you think that there is any other information that we should be aware of, please fill in the box below:

Declaration
In submitting this electronic claim form, I / we declare that the above statements and particulars are true and complete to the best of my/our knowledge and belief and that no material facts have been withheld, misrepresented or mis-stated.
Name:
Position:
Date:	click on calendar to choose date