Temporary Additional Driver

Temporary Additional Driver
1. Your Details:
Relationship Direct Customer Broker
Policy Number
Name
Registration Number
Contact Phone Numbers
Home
 
Work
Mobile
Email Address
2. Effective Date of Cover :
When do you require cover to start?
Date
 
Time
  
       
When do you require cover to cease in respect of this driver? Date
  Time  
Note: If you wish to cover the temporary driver in excess of 15 days please contact the Motor Team on (01) 6363524.
3. Details of Temporary Driver (please be as accurate as possible):
Full Name
Date Of Birth
Licence Type

Full
Provisional
Licence Country of Issue
Has this driver:  
a) resided outside the Republic of Ireland or the United Kingdom during the past 3 years ?
YES NO
b) suffered from Diabetes, Epilepsy, Heart Condition or any other physical or mental disability, infirmity or disease?
YES NO
c) ever had any motor insurance declined or cancelled?
YES NO
d) If the answer to any of the questions a) to c) above is ‘YES’ please give full details in the box below .
e) ever been convicted of an offence in connection with a motor vehicle or have any prosecutions pending ?
YES NO
f) ever been convicted of, or are there any prosecutions pending for any other criminal offence?
YES NO
gf) had a driving licence suspended at any time?
YES NO
h) had, during the last 4 years any accident, loss or claim (whether no claims discount was protected or not) in connection with any motor vehicle?
YES NO
i) If the answer to any of the questions e) to g) above is ‘YES’ please give full details in the box below .
Please note the following

1) There may be an adjustment in premium for this alteration. In the event that you require immediate confirmation of cover, please contact the Motor Team on (01) 6363524 during normal office hours 9am to 5pm, Monday to Friday excluding Bank Holidays.

2) Direct and Brokers without a Delegated Authority Agreement
Please note submission of this form does not automatically change the cover under this policy until expressly confirmed by the company.

3) Brokers with Delegated Authority Agreement
Please Refer to your Delegated Authority Agreement
a) If this alteration falls within parameters of your Delegated Authority, cover is effective as requested.
b) If the alteration falls outside these parameters of your Delegated Authority submission of this form does not automatically change the cover under this policy until expressly confirmed by the company.