Lost Certificate Declaration - DOC

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					                         LOST CERTIFICATE DECLARATION


  Form of Application for Replacement of Lost or Destroyed Certificate of Motor
                         Insurance Road Traffic Act 1972



Policyholder:
Policy Number:
Certificate Number(s):
Expiry Date:


I/We hereby declare that the current Certificate of Motor Insurance in respect of the Insured
vehicle(s), registration number(s): _______________________________________________
delivered to Me/Us by the insurer in accordance with statutory, has become lost, mislaid or
destroyed.
I/We undertake to return the missing certificate to my insurance broker/City Underwriting
Services Ltd if found prior to its expiry date.
I understand in the event of My/Our wishing to cancel, suspend or transfer the policy during
the current period, I/We may be called upon to furnish a statutory declaration relating to the
loss or destruction of the certificate.

Name: __________________________________________


Signed: __________________________________________


Date: ___________________________________________

				
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posted:10/1/2012
language:English
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