University of Warwick Students Union

CAR/7/8 SEATER MINIBUS CARD NO. VAN

DATE OF ISSUE: AUTHORISED:

WARWICK SU AND WARWICK SPORT DRIVER APPLICATION To be completed by those people wishing to be insured to drive vehicles on behalf of Warwick SU and Warwick Sport

UNIVERSITY STAFF/STUDENT NUMBER NON EU DRIVERS NO ------HOW MANY YEARS DRIVING IN UK------

SURNAME FORENAMES

TERM-TIME ADDRESS

TEL NO EMAIL ADDRESS

AGE DATE OF BIRTH

CLUB/SOCIETY/DEPT (STAFF) UNIVERSITY COURSE

UK/EU DRIVER NO. DATE DRIVING TEST PASSED

WHICH CLASS OF VEHICLES HOW MANY YEARS DRIVING EXPERIENCE

Do you suffer from any form of illness or disability which has to be declared to the Authorities to obtain a driving licence? YES/NO If yes, please specify:

Have you ever been involved in any accident in connection with a motor vehicle? YES NO

DATE DETAILS OF ACCIDENT TOTAL COST (Own and third party)

Have you ever been convicted (or are there any prosecutions outstanding) for any offence in connection with a motor vehicle? YES NO If yes, give details below.

DATE OF DATE OF ACCIDENT TYPE OF CONVICTION CODE PENALTY POINTS OFFENCE NO

WARRANTY I warrant that the above statements are true and complete and there are no material facts which would influence the acceptance or assessment of my proposal. I warrant that a charge equivalent only to running costs will be made to persons carried in the vehicle and that the official capacity of the vehicle will not be exceeded.

I understand that any failure to disclose any material facts may prejudice entitlement to indemnity under the insurance contract and I will be liable for all consequences of such failure.

SIGNED: DATE NEWDRIVER PREVIOUS LICENCE : Card and Sheet PHOTO DEPOSIT D1 CLASS Associate Member DRIVER

Please Tick off all documents Received

14.08.13/ls