Staff Driver S Declaration for Vehicle Insurance

STAFF DRIVER’S DECLARATION FOR VEHICLE INSURANCE

All staffrequesting approval to driveUniversity owned, leased or hired in vehiclesmust complete this declaration and enable the University to verify your driving licence. In order to do this you should either:

a)Visit the Transport Office (1 Guildhall Walk) with your original driving licence (both parts). Your declaration will be noted to show that we have seen and verified your licence or

b)Send a copy of your licence (both parts) to the Transport Office who will verify the details and treat the copy as confidential waste.

Surname: / First Name:
Department / Telephone Extension Number:
Date Passed Test: / Do you have a full UK licence? / YES / NO
Please state the number of years experience you have of driving in the UK (min 2 yrs). / Years
Is the address on your driving licence your current permanent address? / YES / NO
(1) / Have you been involved in any motor accidents during the past 3 years? / YES / NO
(2) / Have you ever been convicted of any motoring offences during the past 5 years, or is there any prosecution pending? / YES / NO
(3) / Do you suffer from a notifiable condition not notified to the DVLA or any condition for which DVLA have restricted the licence? / YES / NO
(4) / Have you ever had any motor vehicle insurance you hold or have held, declined, cancelled or refused at normal terms? / YES / NO

If the answer to questions 1-4 is “YES,” full details must be supplied and submitted to the University Insurance Officer (023 92 843308) for approval. A copy of your licence will be sent to our insurers.

(5) / Will you be driving a minibus on University business? . / YES / NO
(6) / If the answer to question 7 is Yes, Do you have a category D1 driving licence? / YES / NO
(7) / Will you be driving an MPV? (Note – a medical will be required) / YES / NO
(8) / Will you be driving a van? (Note – a medical will be required) / YES / NO

Staff must be over 25 years of age; been driving for 2 years; have a category D1 on their Licence and passed medical/driving assessment to drive a Minibus.

I hereby warrant and declare that the above statements and particulars are true and there is no material fact which should be disclosed. I agree to advise immediately any changes in particulars. I understand that this data will only be used for the purposes of motor insurance and will be held in accordance with the Data Protection Act, 1998.

Signature: / Date:

Office Use Only:

Driving licence seen and verified.

Signature………………………… Name ……………………………… Date …………......