Motor Sports - Questionnaire

Insured’s Name ______DOB ______State ______q M q F Height ______’______” Weight ______lbs. Face Amount $______Tobacco use in the past 5 years? q Y q N Details ______Producer ______State ______Phone ______Email ______

Proposed Insured please answer the following:

1. Are you affiliated with any racing organizations? q Yes q No If yes, provide dates: ______

2. What type of car do you use for racing? q Stock Car q Sports Car q Midget q Modified q Dragster q Other(s) ______

3. What type of course do you race on? q Paved Track q Dirt Track q Closed road or airstrip q Oval q Drag Strip q Other(s) ______

4. What type(s) of racing do you participate in? q Professional q Amateur q Speed q Skill q Other(s) ______5. What type of fuel do you use? ______

6. What is the average length of track? ______

7. What is the average number of miles per race? ______

8. Give the maximum speed you have reached in racing: ______mph

9. Do you participate in any other type(s) of racing? q Yes q No If yes, provide details: ______

10. Number of races you have entered in the last 12 months? ______

11. Number of races you expect to enter in the next 12 months? ______

THIS IS NOT AN APPLICATION FOR INSURANCE

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1. Are you affiliated with a racing organization? q Yes q No If yes, provide details: ______

2. What type of event do you participate in? q Scramble Meets q Hill Climbing q Road or q Other(s) ______

3. What size and type of motorcycle do you race? ______

4. Number of races you have entered in the last 12 months? ______

5. Number of races you expect to enter in the next 12 months? ______

Motorboat Racing

1. Are you affiliated with a racing organization? q Yes q No If yes, provide details: ______

2. What type of event do you participate in? q Local q National q For record speeds q Other(s) ______

3. Describe your boat: Type ______Length ______Class ______Motor size ______

4. Give the maximum speed you have reached in racing: ______mph

5. Number of races you have entered in the last 12 months? ______

6. Number of races you expect to enter in the next 12 months? ______

Additional Information:

Insured’s Signature ______Date ______

THIS IS NOT AN APPLICATION FOR INSURANCE

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