Castle Race Series Bicycle Theft Claim Form

Name*
Prefix First Last
Email*
Date of birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Mobile number*
Date of your Castle Race Series event*
MM slash DD slash YYYY

Name of the event*
Date of event*
MM slash DD slash YYYY
Please list all of the items insured under your policy which were stolen in the incident*
Approximate total vale of stolen items*
Please describe in as much detail as possible the circumstances in which the theft took place. Please include the location of the bicycle at the time of the theft, as well as how entry/access was gained.*
Who was responsible for the bicycle at the time of the theft?*
How long was the bicycle left unattended?*
Time and date the bicycle was last seen you*
Time and date theft was discovered*
Were there any witnesses to the theft?*
- Yes
- No
Please provide witness details including name and address.*

Please detail how the bicycle was secured when it was stolen*
If the bicycle was secured with a bicycle lock, please detail the lock make and model*
If the bicycle was stolen from a vehicle, how was access gained to the vehicle, and which security devices were fitted and in operation at the time?*
If a bicycle was not required at the time of the theft, please state the alternative security methods in place*

Have you ever insured your bicycles with another insurer?*
- Yes
- No
Previous insurer name*
Expiry date*
MM slash DD slash YYYY
Please provide details of any bicycle or cycling related claims made in the past three years. Please indicate if no claims.*
Do you have any criminal convictions which you are required to disclose?*
- Yes
- No
Have you ever had a policy cancelled or void by an insurer?*
- Yes
- No
Have you ever been refused renewal or had special terms imposed?*
- Yes
- No
If you answered yes to any of the above questions, please provide details here*

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 Yellow Jersey 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.
- I have read and agree to the above declaration

Essentials