MATERIAL AND EQUIPMENT INSURANCE

Name:
Email:
Phone nr.:
Company:

Name of the rally:
Adress of the rally:
Date of the rally:

Name of the driver:
Type of car:
Chassiss number:
Production year:
Value of the car (€):

Surface: Gravel, tarmac or mixed:
Number of stages:
Total stage mileage:

Insurance requested crash damage:
Insurance requested fire:

PMI MOTORSPORT INSURANCE

Visiting address: Varnaveien 34, 1523 Moss
Mailing address: Pb 2171, 1521 Moss
Organisation number: 920 890768