WORLDWIDE RALLY CLAIM - MIS Motorsport

RECLAMAÇÃO DO RALLY MUNDIAL

Please fill the form below

Telefone
Este campo destina-se a fins de validação e deve ser deixado inalterado.
ABOUT YOU
Team Name (if applicable)
Driver's Name*
Primeiro Último
Telefone*
Mobile*
Fax
Correio eletrónico*
Morada*
Morada Morada (Linha 2) Cidade Código Postal País
Policy No*
CLAIM DETAILS
Date of Accident*
Time of Accident*
Event*
Stage No*
Was the driver hurt?*
- Sim
- Não
Did the driver receive medical attention?*
- Sim
- Não
Is the driver likely to be able to race within the next fourteen days?*
- Sim
- Não
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.
Nome*
Position*
Date*