SECTION 1: To be completed by the Insured

Motor Policy Number

First Name of the Insured

Last Name

Address of Insured

E:Mail address

Insured Contact Tel No

SECTION 2: All questions to be answered by the Additional Driver

Title

Mr Ms Mrs Miss Dr Fr

First Name

LastName

Date of Birth

Occupation include part time

Do you hold a full or provisional driving licence

Full Provisional

State class(es) of vehicle(s) covered by licence

Date of issue of licence

Issuing Authority

Date Driving Test passed

Date of issue of first licence

Will you use the vehicle in connection with your own business

Yes No

Will you be the main driver of the vehicle

Yes No

Do you own your own vehicle

Yes No

Have you held insurance in your own name in the last 3 years

Yes No

Have you ever been refused Motor Insurance or had a policy cancelled or special rates or conditions applied

Yes No

Do you suffer from defective vision or hearing, diabetes, epilepsy, heart condition or any other physical or mental infirmity

Yes No

If ‘Yes’ to the above please give details

(a)
Have you been involved in a traffic accident during the past five (5) years

Yes No

(b)
Have you been convicted by a court of any offence in connection with a motor vehicle

Yes No

(c)
Are there any motor prosecutions pending

Yes No

If the answer to a,b,or c above is ‘Yes’ please give full details

It will also be necessary for you to submit your licence for inspection