Drivers Declaration

Insured (Employer) *

Surname *

First Name *

Address *

Address Line 1

City

State / Province / Region

Zip / Postal Code

Country

Class of License *

License Number *

Expiry Date *

State of Issue *

Date of Birth *

Earthmoving or Miscellaneous Machine *

Yes
No

State Certificate of Competence Number *

Have you ever held a license in another state or under another name? *

Yes
No

Yes, Give Details *

What Date did you commence employment with this current employer *

Have you ever had an accident, fire or theft to a vehicle under your control or made a claim under a motor policy? *

Yes
No

Yes, Give Details *

Accident Details

Date of Accident *

Insurance Company *

Details *

Insured Amount *

Have you ever been charged with an offense in connection with care, control, management or use of a motor vehicle or had a driving license suspended, endorsed or cancelled *

Yes
No

Yes, Give Details *

Offense Details

Date *

Charge *

Offense *

Penalty *

Have you had a medical test in the last 12 months? *

Yes
No

No, When was your last medical test? *

Does the medical test include test for diabetes, sleep disorders, drug use or any other significant medical condition which is reasonably likely to impact your driving capability? *

Yes
No

If a positive result found, please provide further details *

Have you had training in any of the following?

Within the past five (5) years, have you been charged or convicted of any of the following?

If 'Yes' to any of these, please provide details *

In reverse order name your previous 3 employers and time of service.

Repeater Fields

Employer *

Start Date *

End Date *

Our Privacy Policy describes how we collect, disclose. store and use personal information as well as how to access it. correct it Or make a complaint. When we say personal information we may also mean sensitive information such as health information, criminal history or professional memberships that's relevant to us issuing. administering or managing products or providing services and the terms on which we will do these things. We use personal information to issue. administer and manage products and provide services. You can view our Privacy Policy at www.qbe.com.au/privacy or to obtain a copy by phoning us On 133 723 or requesting it from our authorized representatives or service providers.

We may share your information with other QBE Group companies, our authorized representatives and service providers, each of which may be based outside of Australia.

By giving us personal information you consent to us collecting. disclosing. storing and using it in accordance with our Privacy Policy. If you give us someone else's personal information you confirm you've obtained their consent to do so. If you don't provide all of the personal information we've requested we may be unable to issue. administer or manage products or provide services.

I hereby agree that I will upon request. within fourteen days of receiving notice thereof, obtain from the commissioners of transport or the authority having charge of the same. a complete and up-to-date record Of offences in respect of which I have been reported and/or charge and/or convicted in connection with or as a result of the driving of any motor vehicle in any territory of the Commonwealth of Australia or any other place and of all endorsements, suspensions or cancellations of any license which I may have held entitling me to drive any motor vehicle and I hereby agree that if a dispute arises between us. I will not object to the admissibility in evidence of such record or the truth of matters contained therein. I agree that my failure to comply with such request as said will entitle to refuse indemnity under this Policy.

Signature *

Date *

Have you had training in any of the following?

Within the past five (5) years, have you been charged or convicted of any of the following?

In reverse order name your previous 3 employers and time of service.

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