Annual Driver Declaration
Name
*
First Name
Last Name
Phone Number
*
Address (as shown on your license)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driving License Number:
*
Country of Issue (UK/EU only permitted):
*
Date of Issue:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiry Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please upload an image of the front of your license
*
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Please upload an image of the back of your license
*
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Please upload an image of the paper copy of your license (Northern Ireland only)
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Do you have any restrictions?
*
Yes
No
If Yes - please give more information
Do you have any endorsements (penalty points)
*
Yes
No
If Yes - please give more information including the number of points and expiry
Have you ever been disqualified from driving?
*
Yes
No
If Yes - please give more information including the number of points and expiry
Have you ever been convicted of any motoring offences including fixed penalty offences (including any prosecutions pending)
*
Yes
No
If Yes - please give more information
Have you ever had any motor vehicle insurance you hold, or have held, declined, cancelled, or refused?
*
Yes
No
If Yes - please give more information
Declaration: I have read and understood the Centum Vehicle Policy. I certify that the information provided above is correct to the best of my knowledge. I declare myself as medically fit to drive.
*
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