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