No Claims Self Declaration Form (AXA)[1]
2
No Claims Self Declaration Form If you have been a regular driver and accident free for the past 3 years you may be eligible for an introductory discount on your premium by answering the following questions: Have you or anyone who will drive the vehicle had any motor accidents or fault claims in the past 3 years? Yes / No If yes, please give details in the box below. Have you had a valid license and been regularly driving for the past 3 years? Yes / No If no, please give details in the box below. Details of Previous Insurance Companies Period of Cover Insurance Company Policy Number Country Further Details Declaration I hereby declare that the above statements and particulars are true and I have not suppressed, misrepresented, mis-stated or concealed any information. I understand that regular audits are undertaken to verify the validity of the information provided and that if any information is found to be incorrect my policy or any subsequent claim may be invalidated.
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Transcript of No Claims Self Declaration Form (AXA)[1]
No Claims Self Declaration Form
No Claims Self Declaration Form
If you have been a regular driver and accident free for the past 3 years you may be eligible for an introductory discount on your premium by answering the following questions:
Have you or anyone who will drive the vehicle had any motor accidents or fault claims in the past 3 years?
Yes / No
If yes, please give details in the box below.
Have you had a valid license and been regularly driving for the past 3 years? Yes / No
If no, please give details in the box below.Details of Previous Insurance Companies
Period of Cover Insurance CompanyPolicy NumberCountry
Further Details
Declaration
I hereby declare that the above statements and particulars are true and I have not suppressed, misrepresented, mis-stated or concealed any information. I understand that regular audits are undertaken to verify the validity of the information provided and that if any information is found to be incorrect my policy or any subsequent claim may be invalidated.Full Name (Print) : __________________________________________________
Signed:_________________________
Date: _______________
For Office Use :
Verified
Date Verified by
Comments:
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