On Track Enquiries
Application (UK/Europe)
Application (USA/Canada)
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Race Car On Track - Physical Damage Application Form
USA/Canada
- for UK/Europe
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(Click here for details of cover)
Your Details
Policy Holder's Name:
Address:
Web:
Tel:
Mobile:
Fax:
Email:
Preferred method of contact:
Phone
Fax
Email
Car Details
No. of cars to be insured:
1
2
3
4
Make and model of Car:
Currency:
US $
Canadian $
Total replacement cost of rolling shell/chassis: (US$)
Additional total replacement cost of engine & gearbox: (US$)
Event Details
Championship / Series:
No. of Race Events
No. of ‘Double Header’ Events
No. of Oval / Street Race Events
No. of ‘Double Header’ Street Race Events
No. of Test Days
No. of Oval Test Days
0
1
2
3
4
5
6
7
8
9
10
11
12
0
1
2
3
4
5
6
7
8
9
10
11
12
0
1
2
3
4
5
6
7
8
9
10
11
12
0
1
2
3
4
5
6
7
8
9
10
11
12
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
0
1
2
3
4
5
6
7
8
9
10
11
12
Driver Details
Driver Name
Age
Licence
No. of Years Racing
No. of Years in this Category
Insurance Cover Required
Preferred Sum Insured: (US$)
Please state any specific additional cover / quotes you may require:
Previous Insurance / Accident History
Have you insured before?
Yes
No
If ‘Yes’, please state with whom and at what terms:
Details of accidents by drivers stated above, in last 3 years: (If none, state ‘None’)
Has any insurer ever declined / refused or imposed any special terms on your previous On Track policy?
Yes
No
Declaration
I/we hereby declare that to the best of my/our knowledge, that the statements made in this proposal are true and complete and that I/we have not suppressed or mis-stated any material facts. I/we agree that this application and declaration, together with any information supplied by me/us, shall form the basis of the contract between myself/ourselves and the Insurer. I/we understand that completion of this application form does not bind myself/ourselves or the Insurers to any form of insurance contract.
Name:
Position:
Date:
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