Application for Motorsport Daily Accident Insurance

Motorsport daily accident insurance application

Take out your motorsport daily accident insurance quickly and easily here.
Please send us the completed application form. (* Mandatory fields)

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Vehicle type: *

• Automobile
• Motorcycle

Contract type:

• One-time participation

Start / End *

Please enter the days from… to, or multiple individual dates separated by commas.

Event days (total) *

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10

Venue *

Name of the venue

Street *

…of the venue

House number *

…of the venue

Postal code *

…of the venue

Place *

…of the event

Country *

…in which the event takes place

Data about the applicant

Form of address *-select-MisterMissusDivers

Title *-select-Dr.Prof.

Contact person *

Phone *

E-Mail *

Entitled person in case of survival *

Beneficiary in the event of death *

Optionally included: Eligible persons in the event of survival

Optionally included: Beneficiary in the event of death

Premium calculation

I do… *

• Automobile sport
• Kart sport
• Motorcycle sport
• Motorboat sport

License holder *

• Yes
• No

License Number *

Premium selection | Insurance sums / daily premiums (Please select a premium) *

• Daily premium 1 • Disability benefit EUR 50,000.00 • Maximum investment benefit (400% progr.) EUR 200,000.00 • Death benefit EUR 10,000.00 | (net): 31,00 €*
• Daily premium 2 • Disability benefit EUR 75,000.00 • Maximum investment benefit (400% progr.) EUR 300,000.00 • Death benefit EUR 10,000.00 | (net): 44,00 €*
• Daily premium 3 • Disability benefit EUR 100,000.00 • Maximum investment benefit (400% progr.) EUR 400,000.00 • Death benefit EUR 20,000.00 | (net): 65,00 €*
• Daily premium 4 • Disability benefit EUR 125,000.00 • Maximum investment benefit (400% progr.) EUR 500,000.00 • Death benefit EUR 20,000.00 | (net): 78,00 €*
• Daily premium 5 • Disability benefit EUR 150,000.00 • Maximum investment benefit (400% progr.) EUR 600,000.00 • Death benefit EUR 20,000.00 | (net): 91,00 €*
• Daily premium 6 • Disability benefit EUR 200,000.00 • Maximum investment benefit (400% progr.) EUR 800,000.00 • Death benefit EUR 25,000.00 | (net): 118,00 €*
• Daily premium 7 • Disability benefit EUR 250,000.00 • Maximum investment benefit (400% progr.) EUR 1,000,000.00 • Death benefit EUR 50,000.00 | (net): 162,00 €*
• Daily premium 8 • Disability benefit EUR 300,000.00 • Maximum investment benefit (400% progr.) EUR 1,200,000.00 • Death benefit EUR 100,000.00 | (net): 240,00 €*

* + applicable state insurance tax | The following are also insured free of charge: Rescue costs and cosmetic operations up to EUR 10,000.00, rehabilitation assistance up to EUR 1,000.00

Accident hospital daily allowance with recovery allowance (Please select a premium) *

• *Daily premium 1 (net): 15,00 €*
• **Daily premium 2 (net): 35,00 €*
• ***Daily premium 3 (net): 55,00 €*

*Daily premium 1: 15,00 Euro / day + applicable state insurance tax, **Daily premium 1: 35,00 Euro / day + applicable state insurance tax, ***Daily premium 3: 55,00 Euro / day + applicable state insurance tax

Total daily premium (net in EUR)

Preis: 0,00 €

Daily net premium in EUR, plus the applicable national insurance tax (e.g. Germany 19%)

Annotation / Note (Obligation)

• Every insured event must be reported to the insurer in writing immediately, but no later than within one week. If this obligation is violated, the insurer is released from its obligation to pay the policyholder.

Contractual basis *

• Insurance conditions for motorsport insurance SRC 06/2017

In deviation from point 2 of the Special Conditions for Disability Benefits, the progression is 400%.

Insurance coverage *

• The insurance coverage includes accidents all over the world
• only applies to accidents during motorsport events

In deviation from point 2 of the Special Conditions for Disability Benefits, the progression is 400%.

Place / Date *

Signature of applicant *

• I would like to sign these documents / application and therefore hereby authorize RaceInc to issue a valid certificate for signature on my behalf. I confirm the accuracy of my personal data as shown in the document(s). I confirm that I have read the legal framework for the signature process (https://www.bsi.bund.de/DE/Themen/Oeffentliche-Verwaltung/Moderner-Staat/ElektronischeSignatur/RechtlRahmenbedingungen/rechtlrahmenbedingungen_node.html) and thus accept the signing of the documents.

Data protection *

• Yes, I agree that my personal data will be collected, processed and used by Raceinc. – The Insurance in Motorsport / Trackdayversicherung.de owner Mr. Tobias Groenen to create a one-off offer. The data will only be forwarded to the respective insurance companies for the desired offer. I can revoke this consent at any time with effect for the future by calling 002151-3523051 or by sending an email to groenen@raceinc.de or info@trackdayversicherung.de.

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