3. Declaration:
Note: To enable us to proceed with cancellation of your Policy, we require the return of all Certificates and Discs of Insurance that may be in your possession. Please read this Lost Certificate /Disc Declaration and you must complete the box below.
In pursuance of Article 7 of the Road Traffic Regulations 1962, I , being the person to whom the Certificate of Insurance described below was issued hereby apply to RSA for a new Certificate and/or Disc of Insurance and I declare that the said Certificate and/or Disc has been lost /destroyed under the following circumstances:
