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Please complete the following as accurately as possible.
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| Your age band |
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| Number of years employed with Company |
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| Number of years appropiate licence held |
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| Licence Endorsement points in last 5 years |
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| Do you have any current convictions? |
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| Are Drink or Drug driving offences included? |
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| How many own fault incidents (involving a Third Party) in last 3 years? |
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| How many own fault incidents (own damage only) in last 3 years? |
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| Have you had an eye sight test in last 2 years? |
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| Have you undertaken any vehicle driver training? (online or in car) |
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| Do you have a hands free phone fitted? |
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| Are there any medical reasons that might affect your driving? |
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| Are you taking any medication that might affect your driving? |
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| Have you ever been refused car insurance? |
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| Business miles driven per annum (Car) ** |
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| Business miles driven per annum (Van) ** |
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| Business miles driven per annum (Comm Vehicle) ** |
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** Choose one as applicable
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| Predominant driving environment |
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| Typical length of each journey (excl breaks) |
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| Typical total driving time per day |
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| Time spent driving between 22.00 - 06.00 (as a %) |
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| Typical length of working day |
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| Shift working? |
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| Time critical journeys |
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| I confirm that the above details are correct, and that I have not knowingly witheld any information. |
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| Firstname |
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| Surname |
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| Email |
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