Company Other Driver's Declaration This Declaration is to be completed by a person who may drive, or may be in charge of any vehicle proposed for insurance or already insured by the Company. Policyholder Name * Name of other Driver * Policy Number Date of Birth Occupation * Relationship of Driver to Insured * Contact Number * Email Please answer the following questions fully and carefully bearing in mind the Declaration to be completed below How often will you drive any vehicle belonging to the Insured? * Do you suffer from any physical defect or infirmity? * Yes No How long have you had a full driver's license? Local: Overseas: How long have you regularly driven a motor car? Give details of any overseas driving experiences Have you been convicted of a motoring offence during the past five years or informed that a prosecution is pending? * Yes No Do you hold or have you held a Motor Policy? * Yes No Has any insurer ever: Refused your insurance * Yes No Imposed an excess or any special conditions * Yes No Required an increase premium * Yes No Refused to renew or cancelled your insurance? * Yes No Give full details of any accidents within the last five years Declaration by Other Driver: I declare that the above answers and information are true in every respect and that I have not withheld any material fact. (Privacy Policy) * Date of Declaration Name of Driver Declaration by Insured: I agree that this Declaration shall be deemed incorporated in my proposal to the Company and that if there be any non-disclosure or mis-representation whether then the Policy shall be absolutely void in relation to any accident or incident while any vehicle owned by me is being driven by or in the charge of the Other Driver declared. (Privacy Policy) * Date of Declaration Name of Insured
