Let’s work together.Enfield Self Drive Horse Box Hire Hirers Questionnaire for Insurance Part 1 : Hirer and Driver Information (one form per driver is needed) Hirer's Home Address * How long have you lived at this address? Do you plan to move in the next 12 months? * Yes No Email * Phone (###) ### #### Date of Birth * MM DD YYYY Part Two : Journey Details Dates of Hire (not to exceed 90 days) * From MM DD YYYY * To MM DD YYYY Reason for Journey (e.g. horseshow, vet trip, own box being repaired etc.) * Where are you travelling to? * If hiring for more than one day, please confirm the overnight parking arrangements Address Select all that apply a third party yard your own premises parking on the road Part 3 : Licence information - UK licences issued by DVLA The DVLA record motoring convictions electronically, we need a Check Code from the DVLA to check your licence details. To obtain your Check Code, please phone the DVLA on 0300 083 0013, or log in to the DVLA’s Service here www.gov.uk/view-driving-licence (you’ll need your National Insurance No.) Driving Licence No. * DVLA Check Code * Date Check Code Obtained * MM DD YYYY Part 4 - Licence Information – all licence types Country of Issue of Licence * Period of UK residency (years) * Driving Licence categories held Date(s) Driving Test(s) passed Driving Licence Number * Text Have you ever received a driving ban or disqualification? * Yes No Have you incurred any motoring convictions or offences in the last FIVE years? * Have you ever received a driving ban or disqualification? Yes No If yes, did any of these involve drink or drugs? * Yes No If no - please provide hire firm with evidence of your clean record If yes - please complete the below table and provide hire firm with evidence of your endorsements/convictions Part 5 : Driver Medical Conditions/Disabilities Do you have any medical conditions or disabilities that are notifiable to the DVLA? check here for additional information https://www.gov.uk/driving-medical-conditions * Yes No If yes, have you notified the DVLA? * Yes No If yes, have you been issued with a licence? * Yes No If yes to any of the above, please provide further details below * Part 6 : Driving History Regardless of the circumstances, outcome or fault; have you had any motoring claims or accidents in the last THREE years? If yes, please complete the below table * Yes No Thank you!
