Motor Sports - Racing 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: Auto Racing
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
13516 - 2014/6/27 01 of 02 Motorcycle 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 Scramble Meets q Hill Climbing q Road or Track Racing 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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