Drivers/Riders Personal Vehicle Assurance Form This form must be completed annually by all employees that use own vehicle for work journeys (excluding commuting from home to the employee’s normal place of work) Part One: To be completed by the driver/rider Print Name: Address: Vehicle Registration No: Confirm Yes No I confirm that I use my own vehicle for work journeys. I confirm that my insurance includes business use and that I have provided a copy of my insurance certificate to my Head of Unit or their delegated representative. I confirm that I have a current MOT certificate (where applicable, cars less than 3 years old do not require MOT certificates) for my car and that I have provided a copy of my MOT certificate to my Head of Unit or their delegated representative. I confirm that I have a valid and full UK driving license and that I have provided a current driver license check code (check codes can be produced ) to my Head of Unit or their delegated representative. I confirm that I have no known medical condition that makes it unsafe for me to drive. I confirm that I will ensure my vehicle is maintained in a roadworthy condition. I confirm that I will not smoke/permit smoking in my vehicle whilst travelling with colleagues on work journeys. I agree to the terms and conditions outlined in this declaration and will operate within them. Drivers should retain a copy of this declaration reminding them of University expectations. Signed: Date: Office Use I confirm that I (Print Name)……………………….. have received copies of all necessary documentation on Date…………………. Documents received Yes No Driving License Check Code Insurance Certificate MOT certificate (as applicable)
Drivers/Riders Personal Vehicle Assurance Form This form must be completed annually by all employees that use own vehicle for work journeys (excluding commuting from home to the employee’s normal place of work) Part One: To be completed by the driver/rider Print Name: Address: Vehicle Registration No: Confirm Yes No I confirm that I use my own vehicle for work journeys. I confirm that my insurance includes business use and that I have provided a copy of my insurance certificate to my Head of Unit or their delegated representative. I confirm that I have a current MOT certificate (where applicable, cars less than 3 years old do not require MOT certificates) for my car and that I have provided a copy of my MOT certificate to my Head of Unit or their delegated representative. I confirm that I have a valid and full UK driving license and that I have provided a current driver license check code (check codes can be produced ) to my Head of Unit or their delegated representative. I confirm that I have no known medical condition that makes it unsafe for me to drive. I confirm that I will ensure my vehicle is maintained in a roadworthy condition. I confirm that I will not smoke/permit smoking in my vehicle whilst travelling with colleagues on work journeys. I agree to the terms and conditions outlined in this declaration and will operate within them. Drivers should retain a copy of this declaration reminding them of University expectations. Signed: Date: Office Use I confirm that I (Print Name)……………………….. have received copies of all necessary documentation on Date…………………. Documents received Yes No Driving License Check Code Insurance Certificate MOT certificate (as applicable)
DriversRidersUsingPersonalVehicleAssuranceFormfinal.docx