WORLDWIDE RALLY CLAIM

Please fill the form below

ABOUT YOU
Team Name (if applicable)
Driver's Name*
First Last
Phone*
Mobile*
Fax
Email*
Address*
Street Address Address Line 2 City ZIP / Postal Code Country
Policy No*
CLAIM DETAILS
Date of Accident*
Time of Accident*
Event*
Stage No*
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*
- Testing
- Rallying
Weather Conditions/Track Surface*
Full Details of Accident (including the names of other drivers involved if applicable)*
Make/Model of Vehicle*
Parts Damaged*
Currency*
Estimated Total Damages*
Please advise us of the current whereabouts of this vehicle in case we wish to carry out an inspection*
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 misstated.
Name*
Position*
Date*
Email
This field is for validation purposes and should be left unchanged.

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ABOUT YOU