01327 857213 info@wheelstowork.net



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Details of individual

Conviction History

Please provide details of any incident in which you have been convicted of any offence in connection with a motor vehicle, or have a charge pending.

Conviction 1:

Conviction 2:

Conviction 3:

Accident History

Insurers will want to know how many accidents each driver has had over a period of 5 years. This includes both fault and non-fault accidents, theft, fires and any other such incidents, irrespective of whether a claim was made or not.

Claim 1:

Claim 2:

Medical Questions

Have you been advised to inform the DVLA by your doctor?

Have you ever had a head injury /period of unconsciousness/brain surgery?

Have you ever had epilepsy?

Do you have episodes of fainting? (Other than simple attacks associated with the sight of blood or disturbing news etc)

Do you have dizziness or vertigo? (Exceptions as above)

Do you have diabetes?

SIGHT: Do you have any defect of vision? (Other than requiring correction by spectacles)

HEARING: Do you have any difficulty with your hearing?


The information that I have supplied is accurate and true to the best of my knowledge. I understand that any information which has been provided which is false or misstated, could jeopardise my position in the event of a claim occurring or have my claim repudiated.

Please provide the following supporting documentation on your referral: Drivers Licence (both sides), DVLA Licence Summary, Rider Statement if applicable

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