WSIB Insurance Agency, LLC

Drivers Education Policy Form

Requested Effective Date (mm/dd/yyyy)
Agent
Agency
How did you hear about us?	Carolina Motorsports Park
	Lotus Challenge
	Motorsports Ranch Houston
	MVP Track Time
	NASA Great Lakes
	NASA Mid West
	Referred by a friend
	Other

Primary Driver Information >

First Name
Last Name
Street Address
City
State
Zip
Drivers License #
State of Issuance
Date of Birth (mm/dd/yyyy)

Have you had any moving violations in the last 3 years?	YES	NO	< If YES, How Many?
Have you had any reckless driving and or DUI convictions?	YES	NO
Have you had any on-track incidents in the past 3 years that would have been covered by this policy?	YES	NO

How many years have you been driving in track events?		1-3 years
		4-9 years
		10 or more

How many track events have you previously driven in?		1-5 events
		6-10 events
		11-15 events
		16 or more

Phone # (Day)
Phone # (Cell)
E-mail Address

Will there be more than one insured driver?

Car Information >

Year
Make
Model
Sub-Model
VIN
Mileage
Legal Owner or Loss Payee
Fair Market Value - [stock]
Has the vehicle been modified?	YES NO
If YES, Please list modifications:






Do the modifications increase horsepower?	YES NO
If horsepower increased, by what percentage?
Fair Market Value - [with modifications]

Secondary Driver Car Information >

Year
Make
Model
Sub-Model
VIN
Mileage
Legal Owner or Loss Payee
Fair Market Value - [stock]
Has the vehicle been modified?	YES NO
If YES, Please list modifications:






Do the modifications increase horsepower?	YES NO
If horsepower increased, by what percentage?
Fair Market Value - [with modifications]

Event Information >

DISCLAIMER
Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime in some jurisdictions and subjects such person to criminal and civil penalties in some jurisdictions, including but not limited to fines, denial of insurance benefits, civil damages, criminal prosecution and confinement in state prison.

By completing this application, and in using the SUBMIT button, you are applying for insurance from WSIB only for the coverage specified in the application. Completion of the application in no way binds WSIB to provide insurance for either coverage requested or for coverages not requested on such application.

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