DRIVER REFERRAL FORM
Step 1 Step 2 Step 3 Step 4 Step 5 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: 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: 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. Max. size: 256.0 MBStep
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Details of individual
Full Name
Date of Birth
Address
Type of Licence
How long have you held your licence for?
If you hold a non-UK driving licence, can you confirm what type of licence you have?
If you hold a non-UK driving licence, can you confirm how long you have been a permeant resident in the UK?
Conviction History
Type of Conviction (Criminal/Motoring)
Conviction Code as Shown on Driving Licence
Date of Conviction
If Drink Drive Conviction, What was your blood alcohol level?
Any ban? If so, how long?
Any fine? If so, how much?
Circumstances of Conviction:
What was the result of any prosecutions?
Type of Conviction (Criminal/Motoring)
Conviction Code as shown on Driving Licence
Date of Conviction
If Drink Drive Conviction, what was your blood alcohol level?
Any ban? If so, how long?
Any fine? If so, how much?
Circumstances of Conviction
What was the result of any prosecutions?
Type of Conviction (Criminal/Motoring)
Conviction Code as shown on Licence
Date of Conviction
If Drink Drive Conviction, what was your blood alcohol level?
Any ban? If so, how long?
Any fine? If so, how much?
Circumstances of Conviction
What was the result of any prosecutions?
Accident History
Type of Claim
Circumstance of Claim
Date of Claim
Cost of Claim
Is the claim open or closed?
Type of Claim
Circumstance of Claim
Date of Claim
Cost of Claim
Is the claim open or closed?
Medical Questions
Please list impairments or relevant facts that may have the potential to affect your ability to drive safely. Please consider cognitive impairment / visual deficit / physical limitations / perception and communication needs including receptive and expressive difficulties:
Have you been advised to inform the DVLA by your doctor?
Have you ever had a head injury /period of unconsciousness/brain surgery?
If Yes, please provide details
Have you ever had epilepsy?
If Yes, when was the date of your last attack?
Do you have episodes of fainting? (Other than simple attacks associated with the sight of blood or disturbing news etc)
If Yes, please provide details
Do you have dizziness or vertigo? (Exceptions as above)
If Yes, please provide details
Do you have diabetes?
If Yes, a) is it controlled by insulin? b) is it controlled by tablets? c) have you ever had a hypoglycaemic attack?
SIGHT: Do you have any defect of vision? (Other than requiring correction by spectacles)
If Yes, please provide details
HEARING: Do you have any difficulty with your hearing?
If Yes, please provide details
Declaration
Name
Date
Please provide the following supporting documentation on your referral: Drivers Licence (both sides), DVLA Licence Summary, Rider Statement if applicable