MORIS
On Track Insurance

CLAIM FORM

Driver Details
Team Name:
(if applicable)
Driver's Surname:
Driver's Forename:


Address:
Postcode:
Tel:     Fax:
Email:
Policy No:


The Event
Date of Accident:
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Time of Accident:
Circuit:
Name of Corner on Circuit:
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:
Weather Conditions/Track Surface:
Description of accident:
If 'Other' please provide details:


The Vehicle
Type of Formula/Class:
Parts damaged:
Currency:
Estimated total damages:


Inspection Address

Please advise us of the current whereabouts of this vehicle in case we wish to carry out an inspection:
 

If you think that there is any other information that we should be aware of, please fill in the box below:
 


Declaration

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:
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