APPLICANT Title Initials Surname Date of Birth Select >> Mr Mrs Miss Ms Other Address Postcode Telephone Email Address LIST OF ALL OTHER PERSONS TO BE INSURED Title Initials Surname Date of Birth Select >> Mr Mrs Miss Ms Other Select >> Mr Mrs Miss Ms Other Select >> Mr Mrs Miss Ms Other DETAILS OF COVER REQUIRED (note cover cannot be backdated) Single Trip Annual Multi-trip Policy Start Date Date of first track day Date of last track day Number of inclusive days Approximately how many Track Days have you been on before? Any previous Accidents/Incidents/Claims whilst taking part in a Track Day? Select >> Yes No OTHER COVER OPTIONS (please indicate in appropriate boxes) Part 'A' only Part 'A' & 'B' Activity being undertaken (in full) eg. Motorcycle Track Day/Car Track Day etc Area Select >> UK Europe Worldwide IMPORTANT - MEDICAL CONDITIONS & MATERIAL FACTS You will not be covered: Where at the time of taking out this insurance, (and in the case of Annual Multi-trip at the time of booking each trip), the person whose condition gives rise to a claim: a) is receiving, or is on a waiting list for in-patient treatment in a hospital or nursing home, or b) has received a terminal prognosis, or c) is travelling against medical advice or for the purpose of obtaining treatment, or d) is expected to give birth before or within fourteen weeks of the date of arrival home: e) is suffering or has suffered, from any diagnosed psychiatric disorder, anxiety or depression. Note: The above exclusion applies not only to you, but also to close relatives or other persons on whom the trip depends. For trips outside your home country where at the time of taking out this insurance (in the case of Annual Multi-trip at the time of booking each trip) you answer 'yes' to any of the 'Medical Screening Questions' below, and fail to contact the Medical Screening Line. Medical Screening If you need to telephone the Medical Screening Line, you will be asked simple questions about your medical condition, medication, trips to the doctors, and other related matters. In most cases, cover is provided under normal terms. If, as a consequence of your call, we wish to impose special terms, these will be advised to you immediately, and confirmed in writing. Please note terms may vary depending on destination, period of travel, and other factors. MEDICAL SCREENING QUESTIONS Q.1 Do you have more than one of the following conditions? Asthma (well controlled and not requiring supplementary oxygen) Benign Lumps Cataracts Diabetes (if well controlled and no associated conditions) Gall Stones/Gall Bladder removal Gout Under-active/Over-active Thyroid. Select >> Yes No Q.2 Within the last year, have you been treated as a hospital in-patient or been referred to a specialist consultant? Select >> Yes No Q.3 Have you ever been treated for a breathing or heart related condition (including angina)or circulatory condition including Deep Vein Thrombosis or High Blood Pressure/Hypertension? Select >> Yes No Q.4 Have you ever been diagnosed with cancer? Select >> Yes No If you have answered NO to all questions you do not need to call the Medical Screening Line. If you have answered YES to any of the questions please telephone the Medical Screening Line on 0845 230 5555 between the hours of 8.00am to 6.00pm Monday to Friday to confirm acceptability of cover. Note: You do not need to phone the Medical Screening Line if your trip is within the United Kingdom. DECLARATION I declare to the best of my knowledge and belief I have advised you of all material facts (any fact which is likely to influence the rate of cover to be provided by the Underwriting Agents) and that I have read the Important Notice - Medical Conditions and Material Facts. I understand that you may exchange information with other Insurers or their Agents to check the answers I have provided and you have my authority to do so. Trackcover.com has not provided you with any recommendation or advice about whether this product fulfils my specific insurance requirements and I understand it is my responsibility to investigate this. I agree   Authorised and regulated by the Financial Services Authority. Registration Number 304413
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