NOTIFY RALLY / ON EVENT Claim
Team Name:	(if applicable)
Driver's Surname:		Telephone:
Forename:		Mobile:
Address:		Fax:
Post Code:
Email:
Policy No.:

Date of Accident: Time of Accident: Event: Stage No.: Was the driver hurt? Select One No Yes Did the driver receive medical attention? Select One No Yes Is the driver likely to be able to race within the next fourteen days? Select One No Yes Was the accident during: Select One Testing Rallying Weather Conditions / Track Surface: Select One Wet Dry Greasy Icy Snow     Full Details of Accident (Including the names of other drivers involved if applicable):   Make / Model of Vehicle:      Parts Damaged: Currency:  Select GBP EUR USD Estimated Total Damages:      Please advise us of the current whereabouts of this vehicle in case we wish to carry out an inspection:   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 mis-stated.   Name:  Position:  Date: