Request for motorsport accident insurance

Motorsport accident insurance application

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

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Form of address *-select-ManWomanDivers

Contact person *

First Name, Second Name

Company

E-Mail *

Street *

House number *

Postal code *

Location *

Land *

Birth date *

Tax identification number *

Insured person (if not policyholder)

First Name, Second Name

Form of address-auswählen-ManWomanDivers

E-Mail

Street

House number

Location

Land

Birth date

Tax identification number

Type of Motorsport *

Marital status: *

• Single
• Married
• Divorced

Current professional activity / industry / type of business *

Annual income in EUR *

Employment relationship *

• Employed
• Self-employed
• Public service

Beneficiary in the event of survival *

• Policyholder
• Insured person
• Other

Beneficiary in the event of survival *

First Name, Second Name, Birthdate

Beneficiary in the event of death *

• Policyholder
• Insured person
• Other

Beneficiary in the event of death *

First Name, Second Name, Birthdate

Desired start of insurance: *

Date, time (the contract is automatically renewed if it is not terminated three months before expiry.)

Premium calculation

Ich do… *

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

License holder *

• Yes
• No

License number

Desired payment method *

• annual
• semi-annually + 3%
• quarterly + 5%
• monthly + 7%

Please select a payment method.

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

• Annual premium 1 • Disability benefit EUR 50,000.00 • Maximum investment benefit (400% progr.) EUR 200,000.00 • Death benefit EUR 10,000.00 | (net): – 128,00 €*
• Annual premium 2 • Disability benefit EUR 75,000.00 • Maximum investment benefit (400% progr.) EUR 300,000.00 • Death benefit EUR 10,000.00 | (net): – 183,00 €*
• Annual premium 3 • Disability benefit 100,000.00 EUR • Maximum investment benefit (400% progr.) 400,000.00 EUR • Death benefit 20,000.00 EUR | (net): – 256,00 €*
• Annual premium 4 • Disability benefit 125,000.00 EUR • Maximum investment benefit (400% progr.) 500,000.00 EUR • Death benefit 20,000.00 EUR | (net): – 311,00 €*
• Annual premium 5 • Disability benefit 150,000.00 EUR • Maximum investment benefit (400% progr.) 600,000.00 EUR • Death benefit 20,000.00 EUR | (net): – 366,00 €*
• Annual premium 6 • Disability benefit 200,000.00 EUR • Maximum investment benefit (400% progr.) 800,000.00 EUR • Death benefit 25,000.00 EUR | (net): – 485,00 €*
• Annual 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): – 640,00 €*
• Annual premium 8 • Disability benefit 300,000.00 EUR • Maximum investment benefit (400% progr.) 1,200,000.00 EUR • Death benefit 100,000.00 EUR | (net): – 840,00 €*

* + 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) *

• *Annual premium 1 (net) – 40,00 €
• **Annual premium 2 (net) – 80,00 €
• ***Annual premium 3 (net) – 120,00 €

*Annual premium 1: 25.00 euros / day, + applicable state insurance tax || **Annual premium 2: 50.00 euros / day, + applicable state insurance tax || ***Annual premium 3: 75.00 euros / day, + applicable state insurance tax

Total annual premium (net in EUR)

Preis: 0,00 €

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

SEPA direct debit mandate / direct debit authorization (mandatory) (annual payment method)

Creditor identification number: DE18SRC00000498807

Does not apply to customers outside Germany, an invoice will be issued here.

IBAN *

BIC *

Bank *

Account holder *

Date *

Direct debit authorization *

• I/We authorize the payee to collect payments from my/our account by direct debit. The following also applies to SEPA direct debits: At the same time, I/we instruct my/our bank to honor the direct debits drawn by the payee on my/our account. Note: I/we can request reimbursement of the debited amount within eight weeks, starting from the debit date. The conditions agreed with my/our bank apply.

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 the policyholder *

• 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.

Place / Date *

Signature of insured person *

• 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.

Place / Date

Signature of the legal representative

• 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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