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Work Details
Driving History
A) Have you any physical or mental infirmity or ever suffered from diabetes, epilepsy, fits, or any heart complaint?
B) Have you been convicted or have you any prosecution pending for any motoring offence or has your licence been suspended or endorsed?
C) Have you been involved in any motor accident(s) in the last three years?
D) Have you ever been refused or declined motor insurance or had increased premiums or terms imposed?
If you have answered YES to any of the above please give full details:
Driving License
Proof of Address
Must be a passport or utility bill
Must be a utility bill or bank statement
DVLA Licence Check
Please complete the online DVLA licence check (THIS ONLY APPLIES TO UK LICENCE HOLDERS) and share this with us.
This can be completed at the DVLA website. Once completed please take a screenshot of the conformation or enter your share code below.
Important: • CASE SENSITIVE • Can be used ONLY ONCE • Valid for 21 DAYS
Full name(s) of all other persons who may drive:
Maximum additional drivers reached
(Please ensure any additional drivers also complete a separate proposal, and submit documents, drivers must be approved in writing before driving the vehicle, and named on the hire agreement)
I hereby warrant the truth of the above statements and declare that I have withheld no information whatsoever that might tend in any way to increase the risk of the Hirers or Insurers or influence the acceptance of this proposal. I agree that this proposal shall be the basis of the contract between me and the Insurers and I further agree to be bound by the terms, conditions and limitations of the Policy (a copy of which is held at the lessor's head office) which I have had the opportunity to see and read. I further declare that the vehicle is suitable for the purpose of which I am to use it and I will make no claim against the Hire Company for the repayment of any hire charges or any other claim against the Hire Company should the vehicle be unsuitable for the purpose. In the event of a breakdown of the vehicle a refund or compensation will only be paid in accordance with the terms and conditions of the hire contract and in any event would not be greater than the hire cost. I further declare that my occupation, personal details and driving record do not render me ineligible to hire. I authorize the owner to charge to me or my credit/debit card the costs and charges and any extended hire periods as set out in the hire agreement which I have seen and read.
Please sign to state that you agree with the above terms and you will not allow any person whose name is not stated on this form to drive the vehicle
Personal Information
First Name:
Last Name:
Email:
Phone:
Mobile:
Nationality:
Date of Birth:
Age:
Address Details
Address:
Postcode:
New Address:
Work Information
Occupation:
Employer's Name:
Work Phone:
Hire Details
Reason for Hiring:
Area of Use:
Expected Mileage:
Driving History
Physical or Mental Condition:
Motoring Offence:
Motor Accidents in Last 3 Years:
Insurance Refusal or Increased Premiums:
Additional Details (if any):
Additional Drivers
Agreement
Signature:
Date: