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Currency [0]/Explanatory TextG5Explanatory Text % 0Good;Good  a%1 Heading 1G Heading 1 DTj%[2 Heading 2G Heading 2 DTj%?3 Heading 3G Heading 3 DTj%234 Heading 49 Heading 4 DTj% 5InputuInput ̙ ??v% 6 Linked CellK Linked Cell }% 7NeutralANeutral  e%"Normal 8Noteb Note   9OutputwOutput  ???%????????? ???:$Percent ;Title1Title DTj% <TotalMTotal %[[= Warning Text? Warning Text %XTableStyleMedium2PivotStyleLight16`6ISheet1-iSheet2jSheet3,S HD PLEASE COMPLETE IN BLOCK LETTERSDETAILS OF POLICY HOLDERDETAILS OF ADDITIONAL DRIVER7UNIVERSITY COLLEGE LONDON - MOTOR INSURANCE DECLARATION:Insurance for additional driver to commence on (dd/mm/yy) Date of Birth% Total use of vehicle Type of UKlicence(full or prov.) Date passed UK drivingtestPeriod of residence last 3 years1. Has the additional driverYesNo b) ever been convicted of any offence involving dishonesty of any kind e.g. fraud, robbery, theft, arson or handling stolen goods? a) in the past 5 yrs been convicted of any offence in connection with a motor vehicle or is in any such prosecution pending?b d) ever been refused insurance or quoted an increased premium or had special terms imposed?m e) ever suffered from any heart complaint, diabetes, fits, or any other mental or physical infirmity?U If you have answered YES to any part of Question 1 please give full details below 2. Has he/she in the past 5 yrs I) owned a car?9 ii) regularly driven vehicles belonging to others?5If YES, state if still owned or give date of disposalIf YES, state name of owner and relationshipa3. State the approximate number of miles the additional driver has driven in the last 12 months. 4. Will he/she use your vehicle a) for business purposes?) b) for travelling to & from work? If YES, state type of businessZ5. State the registration number(s) of the vehicle(s) to be used by the additional driver*6. Will the additional driver be the main user of the vehicle(s)?If YES, state registration No.17. Have you confirmed all the above information with the additional driver? IMPORTANTInsurance Declaration. However, because no list of questions can be exhaustive, please consider carefully whether there is any other special feature of the vehicle's use or of the additional driver's driving history which makes losses more likely to happen or more serious if they do. ~If the question you have answered above require you to give further information, please use this space (state question number) DECLARATIONI declare that to the best of my knowledge and belief the answers above are true and all material information as explained above has been disclosed.I agree that if any answer has been written by any other person, such person shall for that purpose be regarded as my agent and not the agent of the insurers. Signature DateOccupation & Nature of Dutiesoutside the UK in The answers you have given to the above questions will usually provide us with sufficient information to enable us to consider this Motor information known to you which could influence our acceptance and assessment of the risk. Material information would include any Please disclose to us below such information even if you have doubts as to whether it is material or not as failure to do so could invalidate the policy.Full Name & Address GOWER STREET LONDON WC1E 6BTHEAD OF DEPT. DECLARATIONName of Department :t c) in the past 3 yrs been involved in any accident or suffered any loss in connection with any motor vehicle?L f) during the last 11 years, have you been disqualified from driving?鶹ýƵվDriving License no:;National Insurance no: (To check licence details with DVLA)DVLA check code:J. /F0sg243c58? #:P ; ccz@ VPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V9HLny;;T33;P- 8b2A 2Z ]QȬb!U"D!AG$iZkV1QV'r8Ǧ[TN2vRTSrS%יqt~{^?_N nъ4AA qIMMz7M????????????@ F `9E>????????@G FEEF m@EEEEEEEGG FEEF E:EEEEEEEGG FEEF E;EEEEEEEGG " FEEABBBBBBBBCG " ABBBBBBBBBBBBC i" >j???????????@  F `9 E>????????@G "F`EFEEEEEEEEGG F`E FCEEEEEEEEGG F`E FAEEEEEEEEGG FEE nBBBBBBBBBCG "FEEEEEEEEEEEEG F EEEEEEHIEEEEG "FEEEEEEEEEEEEG X J M4 J ] ab J M N```Y XKO K ^ `Y K S5 P```Y XLQ L _ cd L T R```Y "FUU@>?@@>@EEEG "FVVGFEGGFGEEEG "FWWCABCCACEEEG "FEEEEEEEEEEEEG F `EEEEEEEEE  E  E GF `EEEEEEEEEZZG X ``````````[[Y F \>EEEEEEEEEZZG BX&:<<<&&&:&<<<&:&jj&&&&Z:: !"#$%&'()*+,-./012345689:;<=>@? 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