IMC Driver's Declaration - IMC Insurance Brokers

Motor Vehicle – Drivers Declaration

This form will guide you through the process of completing your Motor Vehicle Driver's Declaration. It only takes a few minutes, and your responses will be used to generate an official PDF declaration, which we'll email to you upon completion. Please have your Driver's Licence details ready. Let's get started!

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Step 1 of 2

Driver's Details

Name*

First Last

Date of Birth*

Contact Number*

Email*

Licence Number*

Year Licence Obtained*

Duty of Disclosure

During the last 5 years has the driver:

had a motor vehicle accident or loss, a vehicle burnt or stolen or made a claim under a motor policy? (regardless of who was at fault and regardless of whether an insurance claim was made for any loss)*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

had a speeding fines and/or any other motoring offences, or on-the-spot fines, other than parking (infringements) including camera detected offences? If you are unsure of your offences you must obtain a Drivers History Report from your State Vehicle Authority (e.g. Vic Roads, RTA, TMR, DPTI, DOT)*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

had, or will have a Driver’s or Motor Cycle Rider’s Licence cancelled, suspended or any special conditions imposed?*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

had any insurance declined or cancelled, been refused renewal of any insurance or had special terms, conditions or penalty excess imposed?*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

suffered from any physical or mental disability, or medical condition or are dependant on any drug or medication which could affect ones driving performance?*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

been convicted for driving under the influence of alcohol or drugs?*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

been convicted of any offence involving dishonesty?*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

been charged or convicted with any criminal offence?*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

been declared bankrupt?*

Please provide details*

Date of Incident (DD/MM/YYYY)

Details

Amount/Points

Date

IMC Driver’s Declaration

Motor Vehicle – Drivers Declaration

Driver's Details

Duty of Disclosure