Insurance application for the DCSR Misty Valley MTB Challenge

 

• Cyclesure is generously sponsoring all insurance for your bikes, for the duration of this cycle challenge.

• It is an All Risks cover to bikes and accessories such as shoes, helmets, pumps etc.

 

To ensure that you have this cover, you will need to fill in an insurance form prior to your departure.

Fields marked with a * are mandatory.

Personal Details
  
 
Name *
Email *
Cellular No *

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Telephone No *

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Fax No

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Cycle Details
  
 
Make & Model of Frame *
Group Set *
Wheel Set *
Total Replacement Value : R *
 
Accessories
  
   
Heart Rate Monitor
R
  
Cycle Computer
R
 
Helmet Name
R
 
Glasses Name
R
 
Shoes Name
R
 
Clothing
R
 
Pump Name
R
 
 
How would you like us to contact you?
   
* I hereby declare that the information on this application and statement of values is, to the best of my knowledge and belief, true and accurate in every respect and that no fact, circumstance or hazard that could effect the acceptance of my application has been withheld. I confirm that this application and declaration shall be the basis of the contract between Hollard and myself.
Date *
   
Please ensure your details are entered correctly to facilitate a speedy response.
Details Are Correct *
   
 

 

 
Cyclesure FSP Number 3262