Online request for PA quotation

Remarks

Quotation Personal Accident Insurance
Type : Personal Accident Insurance      
Policy Wording : As agreed by Underwriters      
Period of Insurance :   Currency :
Are you requesting this insurance as a :      
Insured Person : Date of birth :
Benificiary : Name Beneficiary :
Main / Usual Occupation : Additional Occupation :
Type of Competition License :  
E-mail : Social Security / Fiscal No. :
Invoice address :
Domiciled Address :
Beneficiary Address :
Participating in (Main championship) : , Race events, Test days.
Additionally participating in : , races, testdays.
As an instructor / driver coach : days per annum.
Cover and Sum insured
  Cover
A(i) Death due to Bodily Injury.  
A(ii+iii) Permanent Total Disablement including loss of eyes and limbs.  
B) Temporary total disablement.  
C) Medical & Evacuation expenses.
 
D) Missed race meeting.  
E) Hospitalization and coma benefit.  
Addition to cover
Do you want to include cover for personal equipment? :
Maximum sum payable
Excess 100 each and every loss
1.000   additional premium 50
 
Secondary cover for loss of helmets, race suits, fire proof clothing, race shoes, race gloves. Losses sustained whilst traveling or at the track. :
Maximum sum payable
Excess 100 each and every loss
2.000   additional premium 80
 
Operative Time of Cover :
Additional information :
• Excluded are any other dangerous sports activities unless informed upfront.
• Excluding any pre-existing medical circumstances.
• Subject to receipt of satisfactory proposal form and justification of the sum insured.
• Premium excluding insurance premium tax where applicable.
• The quoted premium is purely an indication and pending formal approval and acceptance of insured perils and premium by Insurers.
Remarks :
Security : 100% London Markets to be confirmed upon inception