Race fee claim form - Pedal Cover

Information
Please supply your Policy Number*
Policy renewal date*
Photo ID*
Please supply a photo of your passport or driving licence
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.
Proof of address*
Please supply proof of address, e.g. a utility bill, bank statement
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.
Evidence of event entry*
Please supply proof your event entry
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.

Terms and conditions
Terms and conditions*
Please upload the terms and conditions or other written confirmation from the event organiser that entry fees are non-refundable
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB, Max. files: 4.

About you
Title*
- Mr
- Mrs
- Miss
- Ms
- Dr
Name*
First Last
What's your contact email address?*
Date of Birth*
What's your mobile phone number*
Please enter a valid phone number.
Type your postcode or street to find your address
We'll look up your address automatically

ZIP / Postal Code
Address*
Street Address Address Line 2 Town / City Postcode

Event Details:
What is the date of the event?*
What was the cost of event entry?*
What date did you pay for entry?*
What is the fee you are claiming for?*
You can only claim any non-refunded part of your fees.
Is a refund, part refund or race credit available from the event organiser?*
- Yes
- No
Which of the following best describes why you can't attend the event?*
- Injury
- Ilness
- Adverse weather cancelled my event
- Damage occurred to my bike
- My bike was stolen
Please upload your medical note confirming withdrawal*
Claims for illness or injury require a medical report from the Doctor (or qualified Physio) who examined you and advised you not to attend the event
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.
Please describe in full detail what prevented you from entering the event?*

Disclosures
Do you have any criminal convictions which you are required to disclose to us?*
- Yes
- No
Details of criminal convictions*
Have you ever had a policy cancelled or void by another insurer?*
- Yes
- No
Details of cancellation of voidance*
Have you ever had your insurance renewal refused, or special terms imposed?*
- Yes
- No
Details of Insursnce refused or terms imposed*

Declaration
Declaration*
I declare that the information contained in this form is true to the best of my knowledge and I have not withheld any information connected with this claim. I accept that if I exaggerate any part of this claim, or make any false declaration or statement, I shall not be entitled to receive any benefit under this policy in respect of this claim. Furthermore, I accept that any such action on my part may render me liable to prosecution. I further agree to provide any further information or documentation as may be reasonably required. I understand that you may seek information from other insurers to check answers that I have provided. By returning this form electrically via the Pedal Cover website in the absence of a signature constitutes acceptance of the declaration.

IMPORTANT NOTICE: Insurers and their agents share information with each other to prevent fraudulent claims and for underwriting purposes via the Claims Underwriting Exchange register operated by Insurance Datatype Services Ltd. A list of participants is available upon request. The information you supply on this form, together with the information you have supplied on your insurance and any other information related to the claim, will be supplied to participants.
- Yes, I agree

Event withdrawal/Race Fee Claim