PDRA 2024 Contingency Claim Form
Class: Extreme Pro Stock
Car Number
*
Competition Car Number
Driver Name
*
First Name
Last Name
Payee Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-Mail
*
example@example.com
Phone Number
*
Federal ID / SS Number
*
Battery
Braille Battery - B168L
Complete Race Car
Jerry Bickel Race Cars
Cylinder Heads
Edelbrock
Data Logger
Computech Systems (Datamaxx)
Fuel Injection
Edelbrock
Fuel Pump
MagnaFuel (Proof of Purchase Required within Last 5 Years)
Intake Manifold
Edelbrock
Motorsports Insurance
Laris Motorsports Insurance
Oil
Maxima Racing Oils (Buy-In $300 through Steven Boone Racing)
Parachutes
Stroud Safety
Rear Tires
Goodyear Tire
Hoosier Racing Tire
Mickey Thompson Tires
Rocker Arms
JESEL
Seat Belts
Stroud Safety
Spark Plugs
Brisk Racing Spark Plugs (Proof of Purchase Required)
Starter
Meziere Enterprises (Requires Valid Serial # for Verification)
Summit Racing Equipment
No Product Required, Decal Only
Valve Springs
PAC Racing Springs (Proof of Purchase Required within Last 12 Months)
Weather Station
Computech Systems (RaceAir Cloud)
Submit
Should be Empty: