Driving Licence Declaration Form
Drivers Full Name
Date of birth
Driving Licence Details
Type of Licence Held
Licence Valid To
Licence Valid From
Class of Vehicles
Do you have any physical defect or infirmity, defective vision (other than corrected by spectacles) or hearing, diabetic, cardiac, epileptic, asthmatic, lung, mental, alcohol or drug or solvent abuse condition which may effect your ability to drive?
Do you suffer from any disease or infirmity necessitating the use of mechanical aids or the prolonged use of drugs which may effect your ability to drive?
Have you had any driving convictions or offences within the past 5 years or have you any prosecutions pending?
Have you been involved in any accidents or loses, regardless of blame, within the past 5 years?
Has any motor vehicle insurer, declined a proposal, cancelled or refused to renew insurance cover or imposed special terms or conditions of insurance?
If you answered YES to any of the above questions give details