A) Have you any physical or mental infirmity or ever suffered from diabetes, epilepsy, fits or
any heart complaint?
B) Have you been convicted or have you any prosecution pending for any motoring offence or has
your licence been suspended or endorsed?
C) Have you been involved in any motor accident(s) in the last three years?
D) Have you ever been refused or declined motor insurance or had increased premiums or terms
imposed?
If you have answered YES to any of the above please give full details
