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Off Track Supplemental Application

Applicant:

Name:
Address:
City:	State:   Zip:
Phone#:
e-Mail:

Strorage:

1. Vehicle kept in locked storage? Yes No
2. Loaned or rented to others? No Yes

   If Yes, explain:

3. Sanctioning Body: ORSCA ADRL IHRA Other Class: Outlaw 10.5 Limited Street Modified Street EZ Street 5.0 Index 6.0 Index 7.0 Index
4. Are you required to add others for coverage under this policy? Yes No
5. Are trailers enclosed? Yes No

   If No, explain:

6. Deductibles: Trailer: 1,000 2,500 5,000
   Scheduled property, Misc. equipment, Tools and Spare parts: 1,000 2,500 5,000 7,500 10,000 15,000
7. Aggregate limit: Maximum amount of payment any one occurrence:
8. Lay Up Period (from/to):   Is all equipment laid up and in storage for more than 4 months a year? Yes No
   If yes, how long?
   Is storage facility different from your mailing address? Yes No
9. Structure
   • Garage: -- Construction -- Steel Frame (wood) Masonry (block or brick)
   • Roof:
   • How many garage doors?   Are these doors locked? Yes No

   If No, explain:

   
   • How many windows?   Are windows barred? Yes No
   • Does the garage have an operating sprinkler system? Yes No
   • Are flammables or chemicals stored in this garage? Yes No
   • Is there a fire extinguisher in the garage? Yes No
   • Has an alarm system been installed? Yes No

   If Yes, Details:

       Is the alarm in working condition? Yes No
   • Do you store any covered items outside while at your shop? Yes No

   If Yes, Details:

   • Is the outside yard adjacent to the shop secured? Yes No

   If Yes, Details:

   • Please list any other precautions taken in order to reduce loss
10. Remarks: ( Use for general information )
    Certificates of insurance, peculiarities of coverage, special coverages, conditions or operations that might affect the exposure.
11. If no auto coverage has been submitted in conjunction with this account please provide a complete drivers list including name, date of birth, driver’s license number and license state.

    Name	DOB	DL#	State

12. Schedule of Equipment: Include Competition Vehicles, Parts, Tools , Equipment, Etc. to be insured Under this policy.

    Competition Vehicle/Race Car Chassis	Price Includes Engine?	Insured Value (stated amt)
    	Yes No
    	Yes No
    	Yes No
    	Yes No
    	Yes No
    	Yes No

    Equipment ( tools, spare parts, etc. ) List all items over $1,000	Serial#	Insured Value (stated amt)