Quotation Personal Accident Insurance
Insurance Type :
Personal Accident Insurance
Policy Wording :
As agreed by Underwriters
Period of Insurance :
Currency :
EUR USD NZD GBP CHF JPY AUD CAD
Are you requesting this insurance as a :
- Choose - Driver/Rider Manager Sponsor Other
Insured Person :
Date of birth :
Beneficiary :
Name Beneficiary :
What is the relationship of the beneficiary? : Spouse :
Main / Usual Occupation :
Professional Race Driver (paid driver) Semi professional Race Driver Other => usual occupation: Student / Scholar Additional Occupation :
Type of Competition License :
n/a National International n/a Club level National A National B National C Super License FIA International Grade A FIA International Grade B FIA International Grade C FIA International Grade R
Email :
Social Security / Fiscal No. :
Company / Invoice address :
Select Australia Austria Belgium Canada Croatia Cyprus Czech Republic Denmark Finland France Germany Greece Hong Kong Hungary Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macao Malaysia Malta Monaco Netherlands New Zealand Norway Poland Portugal Romania Spain Switzerland Taiwan, Province of China United Arab Emirates United Kingdom United States Virgin Islands, British Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote D'Ivoire Cuba Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Ghana Gibraltar Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Iceland India Indonesia Iran, Islamic Republic of Iraq Israel Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Lebanon Lesotho Liberia Libyan Arab Jamahiriya Macedonia, the Former Yugoslav Republic of Madagascar Malawi Maldives Mali Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Puerto Rico Qatar Reunion Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Syrian Arab Republic Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
State / county / canton
Domiciled Address :
Select Australia Austria Belgium Canada Croatia Cyprus Czech Republic Denmark Finland France Germany Greece Hong Kong Hungary Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macao Malaysia Malta Monaco Netherlands New Zealand Norway Poland Portugal Romania Spain Switzerland Taiwan, Province of China United Arab Emirates United Kingdom United States Virgin Islands, British Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote D'Ivoire Cuba Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Ghana Gibraltar Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Iceland India Indonesia Iran, Islamic Republic of Iraq Israel Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Lebanon Lesotho Liberia Libyan Arab Jamahiriya Macedonia, the Former Yugoslav Republic of Madagascar Malawi Maldives Mali Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Puerto Rico Qatar Reunion Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Syrian Arab Republic Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Beneficiary Address :
Select Australia Austria Belgium Canada Croatia Cyprus Czech Republic Denmark Finland France Germany Greece Hong Kong Hungary Ireland Italy Latvia Liechtenstein Lithuania Luxembourg Macao Malaysia Malta Monaco Netherlands New Zealand Norway Poland Portugal Romania Spain Switzerland Taiwan, Province of China United Arab Emirates United Kingdom United States Virgin Islands, British Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote D'Ivoire Cuba Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Ghana Gibraltar Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Iceland India Indonesia Iran, Islamic Republic of Iraq Israel Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Lebanon Lesotho Liberia Libyan Arab Jamahiriya Macedonia, the Former Yugoslav Republic of Madagascar Malawi Maldives Mali Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Puerto Rico Qatar Reunion Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Syrian Arab Republic Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Participating in (Main championship) :
Additionally participating in :
As an instructor / driver coach :
Addition to cover
Do you want to include cover for personal equipment? :
Secondary cover for loss of helmets, race suits, fire proof clothing, race shoes, race gloves. Losses sustained whilst traveling or at the track. :
Operative Time of Cover :
OTC1) 24 hours (At any time during the Period of Insurance) OTC2) Occupational Including Commuting (Whilst an Insured Person is carrying out their occupational duties for the Insured including whilst travelling between their place of residence and place of work) OTC3) Occupational Excluding Commuting (Whilst an Insured Person is carrying out their occupational duties for the Insured but excluding whilst travelling between their place of residence and place of work) OTC4) Business Travel (Whilst on an Insured Journey including Incidental Holidays) OTC5) All Travel (Whilst on an Insured Journey but without requirement for the Insured Journey to be in connection with the Insured`s Business) OTC6) Other (As described in the Specifications)
Additional information :
Cover following Bodily Injuries Cover following Bodily Injuries or Illness
Disability defined as following any and every occupation Disability as defined from usual occupation
• 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 and/or A-rated security, to be confirmed upon inception
We understand that it may not be easy to decide which insured options and sums insured you may require. We therefore offer you the option of a financial analysis and a tailormade quotation. For this you need to complete your client profile. Do you wish to complete your client profile?