Motorsport kart storage insurance notification procedure

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Claims: Karting -> Notification

Personal Details

Name of insured:
Team Name: (if different from above)
Address:
Tel:
Fax:
Email:
Garage Address: (if different from above)
Policy No:

Loss Details

Date of loss:
Time of loss:
Type of Loss:	Accidental Damage - Section (A) Theft - Section (B) On Track Physical Damage - Section (C)

Section (A) - Accidental Damage Give full details of circumstances, including time and date discovered and situate of loss:

Estimated Value:

Section (B) - Theft Give full details of circumstances, including time and date discovered, address and situate of loss:

Police Crime Ref No:
Estimated Value:

Section (C) - On Track Physical Damage Give full details of where the incident took place, including Circuit name, date and event meeting, serial number of chassis / engine / computer if applicable, name of Scrutineer and his license number (immediately prior to damage occuring), class of racing contested, full details of items damaged, along with any other relevant information. (Send all relevant photograph(s) of damaged item(s)) under separate cover to: Everitt Boles Ltd, 15 St Helen's Place, London EC3 6DE

Estimated Cost:
Outline Area of Damage: (please tick the appropriate box(es))	A B C D E F

In submitting this electronic claim form, I/we declare that the above statement 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: Date:

Credit and Debit Cards accepted

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