Drivers Declaration Form 1. Insured Details Name of Insured * 2. Driver Details Details of whom to the knowledge of the insured will be driving any of the insured vehicles. Name * Date of Birth * How long licensed Occupation Own another vehicle YesNo Registration Number If Yes to the above - name of insurer 3. Accidents / Damage Has this driver ever been involved in an accident, had a theft or fire to a motor vehicle during the past 5 years. Accidents, theft or fire in past 5 years * YesNo Date of most recent accident Brief description Approx amount of damage - own vehicle Approx amount of damage - third party vehicle Insurer of third party vehicle 4. Driving Offences / Convictions Has the driver ever had any of the following. 1. Their license endorsed YesNo 2. Been prosecuted for an offence in connection with intoxicating liquor or any drugs YesNo 3. Had an offence in connection with a motor vehicle in last 5 years (for example speeding, dangerous driving) YesNo Date of offence Nature of charge or prosecution Was license suspended, cancelled or endorsed YesNo Length of suspension or cancellation Amount of fine 5. Duty of Disclosure Additional information 6. Declaration I/We confirm with my/our signature(s) that the information and answers given are truthful, accurate and frank and I/We have not withheld any information. Signature of Driver Date
