Fieldset 5 Closed & Fieldset 6 Loaded:
Are you aged between 25 years and 75 years old? We ask this because driver's aged in this age range fall into our 'Normal Driver' category.
Yes No
Hirers outside of this age bracket are subject to additional insurance excesses.
Have you held your full driving licence for at least 2 years? Has at least 24 months passed since you passed your driving test and were issued your licence?
Yes No
Our standard cover is applicable to Hirers who have been driving for more than 2 years, we will request insurance clearance from our insurers and let you know if there are any additional or special conditions imposed.
How long have you been driving in the UK? You should include all experience of driving a motor vehicle whilst in the UK.
Select... Holiday Visitor Less than 6 Months Less than 12 Months Between 1 and 2 Years Between 2 and 3 Years Between 3 and 5 Years Between 5 and 10 Years Over 10 Years
Have you had any motor accidents, claims or losses, regardless of fault, in the last 5 years? This includes any incidents you were invloved in, irrespective of how minor they may have been, or if they were reported to your insurer.
Yes No
Accident 1: Date of Accident: Please provide the approximate date if you are unsure.
Did you have to pay your excess? You should choose yes, even if you had your excess refunded, repaid, or it was claimed back from another insurer or policy.
Yes No
Were you at fault? Choose yes if you were to blame for the accident or if the insurers decided you were at fault. You should also choose yes if the claim progressed on a 'knock for knock' or 50/50 basis.
Yes No
Were there any injuries to any party involved? Choose yes if there were any injuries sustained by you, any of your passengers, any other party involved, or any of their passengers.
Yes No
Has the Claim been fully settled, or is it still ongoing? Only choose settled if you are 100% sure the insurer has recovered all their losses and closed their file. Choose ongoing if the claim is still ongoing or you are unsure of the status.
Settled Ongoing
What was the total value of the claim? You should include the cost of repairs to your vehicle, injury settlement, replacement/hire car costs, and any uninsured losses that were claimed against you.
Select... Less than £1000 Between £1001 - £3000 Between £3001 - £5000 Between £5001 - £7500 Between £7501 - £10,000 Between £10,001 - £15,000 Between £15,001 - £20,000 Over £20,000
Please describe the circumstances of the accident: Please describe the circumstances surrounding the accident, what happened, what speeds were involved, etc. We need this information to ensure you are appropriately covered by the vehicle insurance.
Do you have another accident to report? This includes any incidents you were invloved in, irrespective of how minor they may have been, or if they were reported to your insurer.
Yes No
Accident 2: Date of Accident: Please provide the approximate date if you are unsure.
Did you have to pay your excess? You should choose yes, even if you had your excess refunded, repaid, or it was claimed back from another insurer or policy.
Yes No
Were you at fault? Choose yes if you were to blame for the accident or if the insurers decided you were at fault. You should also choose yes if the claim progressed on a 'knock for knock' or 50/50 basis.
Yes No
Were there any injuries to any party involved? Choose yes if there were any injuries sustained by you, any of your passengers, any other party involved, or any of their passengers.
Yes No
Has the Claim been fully settled, or is it still ongoing? Only choose settled if you are 100% sure the insurer has recovered all their losses and closed their file. Choose ongoing if the claim is still ongoing or you are unsure of the status.
Settled Ongoing
What was the total value of the claim? You should include the cost of repairs to your vehicle, injury settlement, replacement/hire car costs, and any uninsured losses that were claimed against you.
Select... Less than £1000 Between £1001 - £3000 Between £3001 - £5000 Between £5001 - £7500 Between £7501 - £10,000 Between £10,001 - £15,000 Between £15,001 - £20,000 Over £20,000
Please describe the circumstances of the accident: Please describe the circumstances surrounding the accident, what happened, what speeds were involved, etc. We need this information to ensure you are appropriately covered by the vehicle insurance.
Do you have another accident to report? This includes any incidents you were invloved in, irrespective of how minor they may have been, or if they were reported to your insurer.
Yes No
Accident 3: Date of Accident: Please provide the approximate date if you are unsure.
Did you have to pay your excess? You should choose yes, even if you had your excess refunded, repaid, or it was claimed back from another insurer or policy.
Yes No
Were you at fault? Choose yes if you were to blame for the accident or if the insurers decided you were at fault. You should also choose yes if the claim progressed on a 'knock for knock' or 50/50 basis.
Yes No
Were there any injuries to any party involved? Choose yes if there were any injuries sustained by you, any of your passengers, any other party involved, or any of their passengers.
Yes No
Has the Claim been fully settled, or is it still ongoing? Only choose settled if you are 100% sure the insurer has recovered all their losses and closed their file. Choose ongoing if the claim is still ongoing or you are unsure of the status.
Settled Ongoing
What was the total value of the claim? You should include the cost of repairs to your vehicle, injury settlement, replacement/hire car costs, and any uninsured losses that were claimed against you.
Select... Less than £1000 Between £1001 - £3000 Between £3001 - £5000 Between £5001 - £7500 Between £7501 - £10,000 Between £10,001 - £15,000 Between £15,001 - £20,000 Over £20,000
Please describe the circumstances of the accident: Please describe the circumstances surrounding the accident, what happened, what speeds were involved, etc. We need this information to ensure you are appropriately covered by the vehicle insurance.
Do you have another accident to report? Choose yes if you were to blame for the accident or if the insurers decided you were at fault. You should also choose yes if the claim progressed on a 'knock for knock' or 50/50 basis.
Yes No
You cannot report more than three accidents through this online declaration.
Have you have any points, convictions, endorsements within the past 5 years for any motoring offence, or any disqualifications within the past 12 years, or do you have any prosecutions pending? Please note that we need all current offences included, even if they show as exipred on your driver record.
Yes No
Please provide further information here: Please note that all current and pending offences must be included, even if they show as exipred on your driver record. We need this information to ensure you are appropriately covered by the vehicle insurance.
Please include the date of the offence, the offence code, or details of what happened, the fine you paid, the points you received, and whether it was dealt with by fixed penalty or through the courts.
In any country worldwide, have you been convicted of any motoring offence or have you received any fixed penalty endorsement within the past 5 years? Please note that all current and pending offences must be included irrespective if they were accrued within the UK or any other country. They must be delcared, even if they show as exipred on your driver record.
Yes No
Please provide further information here: Please note that all current and pending offences must be included irrespective if they were accrued within the UK or any other country. They must be delcared, even if they show as exipred on your driver record. We need this information to ensure you are appropriately covered by the vehicle insurance.
Please include the country who dealt with the offence, the date of the offence, the offence code, or details of what happened, the fine you paid, the points you received, and whether it was dealt with by fixed penalty or through the courts.
In any country worldwide, have you received any motoring endorsement which resulted in a fine exceeding £100.00 within the past 10 years? Please note that all current and pending offences must be included irrespective if they were accrued within the UK or any other country. They must be delcared, even if they show as exipred on your driver record.
Yes No
Please provide further information here: Please note that all current and pending offences must be included irrespective if they were accrued within the UK or any other country. They must be delcared, even if they show as exipred on your driver record. We need this information to ensure you are appropriately covered by the vehicle insurance.
Please include the country who dealt with the offence, the date of the offence, the offence code or details of what happened, the fine you paid, the points you received, and whether it was dealt with by fixed penalty or through the courts.
In any country worldwide, have you received any motoring conviction which resulted in a fine exceeding £100.00 within the past 10 years? Please note that all current and pending offences must be included irrespective if they were accrued within the UK or any other country. They must be delcared, even if they show as exipred on your driver record. Please include any offence or endorsement you may have received, either within the UK or any other country.
Yes No
Please provide further information here: Please note that all current and pending offences must be included irrespective if they were accrued within the UK or any other country. They must be delcared, even if they show as exipred on your driver record. We need this information to ensure you are appropriately covered by the vehicle insurance.
Please include the country who dealt with the offence, the date of the offence, the offence code or details of what happened, the fine you paid, the points you received, and whether it was dealt with by fixed penalty or through the courts.
In any country worldwide, have you been suspended, banned, or disqualified from driving at any time in the past 12 years? Please include any suspension, ban, or disqualification you may have received, either within the UK or any other country.
Yes No
Please provide further information here: Please include any suspension, ban, or disqualification you may have received, either within the UK or any other country. We need this information to ensure you are appropriately covered by the vehicle insurance.
Please include the country who dealt with the offence, the date of the offence, the offence code or details of what happened, the fine you paid, the points you received, and how it was dealt with by the courts.
Have you received any points, endorsement, convictions, suspensions, bans, or disqualifications whilst driving in the UK using your foreign driving licence at any time in the past 12 years? Please include any points, endorsements, convictions, suspensions, bans, or disqualifcations you may have received in the UK while driving with your foreign driving licence.
Yes No
Please provide further information here: Please include any points, endorsements, convictions, suspensions, bans, or disqualifcations you may have received in the UK while driving with your foreign driving licence. We need this information to ensure you are appropriately covered by the vehicle insurance.
Please include the date of the offence, the offence code or details of what happened, the fine you paid, the points you received, and whether it was dealt with by fixed penalty or through the courts.
Do you have a DVLA notifiable medical condition or disability? This only includes medical conditions that the DVLA must be notified of.
Yes No
Please provide further information here: We need this information to ensure you are appropriately covered by the vehicle insurance.
Please include all information surrounding your condition, any medication you may take, and any restrictions that this has on your driving licence.
Has your medical condition or disability changed since you last informed the DVLA? Has anything changed, progressed, got better or got worse since you last informed the DVLA?
Yes No
Have you ever had any insurance declined, renewal refused, had any special conditions or terms imposed, been required to pay an increased premium, or had a policy cancelled by any motor insurer? We need to know if ANY of these statements have EVER applied to you.
Yes No
Please provide further information here: We need to know which of these statements have EVER applied to you, we need this information to ensure you are appropriately covered by the vehicle insurance.
We need to know if ANY of these statements have EVER applied to you. Please include all information surrounding which statement applies, including the date it occurred, what was changed or required by your insurer, and whether these are ongoing.
FS5 - Optional Question: TT Narrative Goes Here.
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Yes
No
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Yes
No
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