WORLDWIDE RACE CLAIM

Please fill the form below

Facebook
Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.
ABOUT YOU
Team Name (if applicable)
Driver's Name*
Prénom Nom
Téléphone*
Mobile*
Fax
Courriel*
Adresse*
Adresse postale Adresse ligne 2 Ville Code postal Pays
Policy No*
CLAIM DETAILS
Date of Accident*
Time of Accident*
Circuit*
Name of Corner on Circuit*
Was the driver hurt?*
- Oui
- Non
Did the driver receive medical attention?*
- Oui
- Non
Is the driver likely to be able to race within the next fourteen days?*
- Oui
- Non
Was the accident during*
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.
Nom*
Position*
Date*

ABOUT YOU