Driver Referral Form

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

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:

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?

Conviction 2:

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?

Conviction 3:

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

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:

Type of Claim

Circumstance of Claim

Date of Claim

Cost of Claim

Is the claim open or closed?

Claim 2:

Type of Claim

Circumstance of Claim

Date of Claim

Cost of Claim

Is the claim open or closed?

Declaration

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.

Name

Date

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

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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