Authorised and regulated by the Financial Conduct Authority Ref No. 308648

International Insurance & Reinsurance

Established in 1820

Tysers is a trading name of Tyser & Co. Ltd. Registered in England No. 4256470. Registered Office: Beaufort House, 15 St Botolph Street, London, EC3A 7EE

INSURANCE APPLICATION FOR TRANS AMERICA 2018

Driver 1 (Proposer) / Have you previously taken part in an organised rally? / Yes / No
If Yes, please list these events?
Name:
Address:
Postal/Zip Code:
Type of Licence: / Licence Number:
(e.g. Full International) / Date Passed Test:
Country of Issue: / Date First Licence Obtained:
Nationality: / Occupation:
Date of Birth: / Industry / Trade:
Passport Number: / Expiry Date:
Driver 2 / Co-Driver / Have you previously taken part in an organised rally? / Yes / No
If Yes, please list these events?
Name:
Address:
Postal/Zip Code:
Type of Licence: / Licence Number:
(e.g. Full International) / Date Passed Test:
Country of Issue: / Date First Licence Obtained
Nationality: / Occupation:
Date of Birth: / Industry / Trade:
Passport Number: / Expiry Date:
If additional drivers are required, please show full details on the supplementary page provided
Your Vehicle – PLEASE ATTACH A PHOTOGRAPH
Are you the owner of the vehicle? / Yes / No
If not, please provide name of owner and the nature of your relationship :
Make/Model: / Year of Make:
VIN / Chassis No: / Engine Capacity:
Passenger capacity: / Current Value in GBP: / £
(including driver) / Please Note: Tysers do not verify the current values of the vehicle, failure to supply the correct value may lead to the vehicle being underinsured.
Country of Registration: / Tools, Spare Parts & Accessories in GBP: / £
Licence Plate:
(of Home Country) / (If insurance is required)
What, if any, is the difference between the normal market value of your car type and the version you have prepared for the event? / £
Claims History / Please state details of any losses(including theft), whether insured or not in last 3 years for each driver including dates and costs for own damage/third party damage explaining circumstances – use a separate sheet if necessary. IF NONE, STATE NONE:
Driver 1:
Driver 2:
Conviction History / Please state any driving convictions for each driver, i.e, speeding, careless driving, drink/drug related offences etc. together with relevant fines / licence endorsements sustained within the last 5 years. IF NONE, STATE NONE:
Driver 1:
Driver 2:
Please complete supplementary page provided for additional drivers / further details
Travel Insurance/ Repatriation Declaration
Have/are you or anyone to be insured on this policy
1. / suffered from or received any ongoing treatment for any heart or cancer condition in the last five years? / Yes / No
2. / currently receiving or have you received in the last 12 months, any advice, medication or treatment for any illness, injury or disease? / Yes / No
3. / under investigation or awaiting results for any diagnosed or undiagnosed medical condition? / Yes / No
4. / travelling against your doctor’s advice, or for the purpose of obtaining treatment? / Yes / No
5. / received a terminal prognosis? / Yes / No
6. / on a waiting list for, or aware of the need for, any in-patient treatment? / Yes / No
If you answered yes to any of the questions please provide further details below, stating which driver it applies too:
By ticking this box I declare that to the best of my knowledge and belief, the statements and particulars in this application form are true and complete and nothing which might influence Underwriters in assessing this insurance has been withheld.
Name in Capital Letters:
Endurance Rally Team Number:
E-mail Address:
Contact Telephone Number:

PLEASE RETURN THIS FORM WITH SCANNED COPIES OF DRIVING LICENCES AND PASSPORTS FOR EACH PARTICPANT TO:

Declaration

We declare that to the best of our knowledge and belief, the statements and particulars are true and complete and nothing which might influence the Underwriters in assessing this insurance has been withheld.

I/We undertake that the vehicle will not be driven by any person who to my/ our knowledge:

a) HAS BEEN REFUSED ANY MOTOR INSURANCE OR CONTINUANCE THEREOF

b) SUFFERS FROM ANY DISEASE, PHYSICAL OR MENTAL INFIRMITY, FITS OR BLACK-OUTS,DIABETES, EPILEPSY, OR ANY HEART COMPLAINTS;

c) HAS DURING THE LAST 5 YEARS BEEN CONVICTED OF THE FOLLOWING MOTOR OFFENCES:

Culpable homicide; Manslaughter; causing death by dangerous driving; dangerous or reckless driving; driving under the influence of alcohol or drugs; failing to stop after an accident; any offence or combination of offences which resulted in a suspension from driving.

Unless such person has been declared to the Underwriters and their permission given for that person to drive the vehicle.

(Please use the reverse of this form to declare such information for consideration by Underwriters)

Please note that under English law, if you are a consumer insured (an individual buying insurance wholly or mainly for purposes unrelated to your trade, business or profession) you have a duty to take reasonable care to answer the insurer’s questions fully and accurately and to ensure that any information that you volunteer is not misleading. This duty exists before your cover is placed, when it is renewed and any time that it is varied, and your policy wording may provide that it continues for the duration of the policy. If you do not do this, your insurer may be able to impose different terms on your cover, may charge you a higher premium or, in some circumstances, may be able to avoid your policy from inception and any claims under it would not be paid.

If you are a business insured (i.e. not a consumer insured) you have a duty to disclose all material facts to the insurer before your cover is placed, when it is renewed and any time that it is varied. Your policy wording may also provide that this duty continues for the duration of the policy. A material fact is a fact which may influence an insurer’s judgement in their assessment of a risk, including its term and pricing. If you are in any doubt whether a fact is material we recommend that it should be disclosed. Failure to disclose a material fact may entitle an insurer to avoid the policy from inception and any claims under it would not be paid.

A material fact is a fact which may influence an Insurer’s/Reinsurer’s judgement in their assessment of a risk. If you are in any doubt as to whether a fact is material, we recommend that it be disclosed. Failure to disclose material facts may entitle (Re)lnsurers to avoid the policy from inception.

ADDITIONAL DRIVERS

Driver 3 / Have you previously taken part in an organised rally? / Yes / No
If Yes, please list these events?
Name:
Address:
Postal/Zip Code:
Type of Licence: / Licence Number:
(e.g. Full International) / Date Passed Test:
Country of Issue: / Date First Licence Obtained:
Nationality: / Occupation:
Date of Birth: / Industry / Trade:
Passport Number: / Expiry Date:
Driver 4 / Have you previously taken part in an organised rally? / Yes / No
If Yes, please list these events?
Name:
Address:
Postal/Zip Code:
Type of Licence: / Licence Number:
(e.g. Full International) / Date Passed Test:
Country of Issue: / Date First Licence Obtained:
Nationality: / Occupation:
Date of Birth: / Industry / Trade:
Passport Number: / Expiry Date:
Claims History / Please state details of any losses(including theft), whether insured or not in last 3 years for each driver including dates and costs for own damage/third party damage explaining circumstances – use a separate sheet if necessary:
Driver 3:
Driver 4:
Conviction History / Please state any driving convictions for each driver, i.e, speeding, careless driving, drink/drug related offences etc. together with relevant fines / licence endorsements sustained within the last 5 years:
Driver 3:
Driver 4: