Self-Drive Licence & Insurance Declaration Form

LICENCE REQUIREMENTS Self Drive Driving Licence Requirements

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Please leave blank:

Company Name:

Age of driver:

Last 8 Digits of driving licence:

Any points on licence:

Name of driver:

Period licence held for:

Any claims made in the last 3 years:

DVLA Check Code:

Please note this is a one time code that can only be used once.

All of the check boxes below must be ticked in order for this form to be submitted *

Please confirm:

The driver using PG Platforms Insurance is aged between 25 – 75

Please confirm:

The driver has held a full licence for at least 2 years if aged 21–24 and 1 year if aged 25 or over

Please confirm:

The driver has not had more than one claim in 3 years and have a clean licence – one fixed penalty for speeding is acceptable without referral

Please confirm:

The driver doesn’t have any medical conditions notifiable to the DVLA and has never been refused insurance

Please confirm:

I accept the insurance covered is for road risk cover only

Please confirm:

I accept PG Platforms ltd will not accept any responsibility for any damage to pavements or roadways caused by the machine whilst on hire

Please confirm:

I accept that in all cases the hirer is responsible for the first £3,000 of any claim

Please confirm:

I understand that only the driver named and confirmed on this form is permitted to drive the hired vehicle. No other drivers are authorised.

Your Name:

Typing your name here will be taken as your electronic signature and confirmation that the information provided is accurate.

Today's Date:

Your Email: