MCCSA – Driver’s License Declaration License Holder's DetailsDriver Full Name(Required) First Last Driver Residential Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth MM slash DD slash YYYY License Number and Class Number of Years Driving ExperienceEmail(Required) Enter Email Confirm Email Has the driver had any criminal convictions in the last 5 years? Yes No Has the driver had their license cancelled, suspended or endorsed in the last 5 years? Yes No Has the driver been fined or convicted of a speeding or any other traffic offence (excluding parking) in the last 5 years? Yes No Has the driver ever had insurance declined, cancelled, renewal refused or special conditions imposed? Yes No Does the driver suffer from any physical or mental disability or medical condition (e.g. diabetes, epilepsy, heart condition, faulty eyesight) which could affect your driving performance? Yes No Please state whether there have been any convictions or fines in the last 5 years for:Alcohol Yes No Dangerous Driving Yes No Drug Offenses Yes No Culpable Driving Yes No If you have answered ‘Yes’ to any of the above, please provide full details (if insufficient space, please attach a separate sheet) FileMax. file size: 50 MB.Claims & Accident HistoryHas the driver been involved in any accidents or lodged any claims in the last 5 years? Yes No If yes, please provide written details of any claims or accidents the driver was involved in within the last 5 yearsDate of Loss, Details of Loss, Approx. Claim Amount DeclarationI hereby declare that:(Required)– I have been truthful and accurate in completing this form and declaration and have no withheld any information. – I have either completed this form personally or, if it has been on my/our behalf, have checked that the questions have been fully and accurately answered. – I have read and understood the Privacy Notice and consent to the collection, storage, use and disclosure of any personal and sensitive information. I agree to the policy.FilePlease provide a driver history printout from a state transport authority.Max. file size: 50 MB.Drivers Name First Last SignatureDate of Declaration MM slash DD slash YYYY CAPTCHA Δ