Drivers Declaration Policy DetailsStep 1 of 6Insured (Employer) *Surname *First Name *Address *Address Line 1CityState / Province / RegionZip / Postal CodeAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKosovoKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis and FutunaWestern SaharaSamoaYemenZambiaZimbabweCountryClass of License *License Number *Expiry Date *State of Issue *Date of Birth *Earthmoving or Miscellaneous Machine *YesNoState Certificate of Competence Number *Have you ever held a license in another state or under another name? *YesNoYes, 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? *YesNoYes, Give Details *Accident Details Date of Accident *Insurance Company *Details *Insured Amount *Add Accident Detail Remove Accident DetailHave 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 *YesNoYes, Give Details *Offense Details Date *Charge *Offense *Penalty *Add Offense Remove OffenseHave you had a medical test in the last 12 months? *YesNoNo, 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? *YesNoIf a positive result found, please provide further details *Have you had training in any of the following?Load Restraint *YesNoVehicle Familiarization *YesNoFatigue Management *YesNoWhat to do if an accident occurs *YesNoDefensive Driving *YesNoHow to use a fire extinguisher *YesNoWithin the past five (5) years, have you been charged or convicted of any of the following?Drug Offense *YesNoCriminal Offense *YesNoAlcohol Offense *YesNoIf '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 *Add previous work detail Remove previous work detailOur 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 *WebsitePreviousNextSubmit Get Unparalleled Cover for Your Business Contact Us