MORIS :: motorsport race & rally insurance services for track day insurance

On Track Application

What your Policy covers • What your Policy does not cover • Policy wording

Existing User?

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Your Details - New User

Title:

Forename:

Surname:

Address Line 1:

Address Line 2:

Town:

County:

Postcode:

Date of Birth [dd/mm/yy]:

Occupation:

Telephone:

Fax:

Mobile:

How did you find us:

Email:

Note: Check email address. If incorrect our formal quotation will not reach you since this is only sent by email

Password:

On Track Details
Number of race meetings that you require cover for
Number of test days that you require cover for:
Date of the first race meeting / test day:	click on calendar to choose date
Expiry Date:	There will be a natural expiry date of 15th November 2005 shown on your certificate.
EERC Class:
All Track name(s): Please indicate whether any of the meetings are doubleheaders by putting "D/H" after the track name.

Vehicle Information
Make:
Exact Model:
Year of Manufacture:
Do you require labour cover for stripping and reassembly?
Name of team that is running the car:
How long have you/they owned this vehicle?	(eg - 1 year, 2 months)
If you are not the owner of the car, please state who legally owns vehicle:
Replacement value of car:	£ no commas or spaces
Amount vehicle to be insured for:	£ no commas or spaces

Incidents and Experiences
Approximately how many races have you previously competed in:
Please give details of the last 3 years experience that you have, including any previous Everitt Boles / MORIS policies: If 'None' state 'None'
Details of any accidents in the last 3 years, including what race(s) you were taking part in, damage caused, costs to repair: If 'None' state 'None'
Details of any claims and convictions on the road within the last 5 years: If 'None' state 'None'
Type of race licence held:
Have you had any licence endorsements/fines:	Yes No
If 'Yes', please specify:

Additional Drivers
Do you require cover for any additional drivers?	Yes No
If Yes, please state name(s):	1. 2.
Please state the following details (1) ages (2) experience (3) accident details (4) details of any licence endorsements / fines:

Additional Material Information
Details of any other material information about the races(s), car(s) or driver(s):

Declaration
Material Facts and Non Disclosure I/we hereby declare that to the best of my/our knowledge, that the statements made in this proposal are true and complete and that I/we have not suppressed or mis-stated any material facts. (Further Details) Policy Wording It is important that you read the policy wording before you effect cover with ourselves. (Policy Wording) Application I/we agree that this application and declaration, together with any information supplied by me/us, shall form the basis of the contract between myself/ourselves and the Insurer. I/we understand that completion of this application form does not bind myself/ourselves or the Insurer to any form of insurance contract. Privacy and Security Important: I/we confirm that I/we have read and understood the above. Further I/we confirm we have checked the accuracy of all information supplied above.