LOST CERTIFICATE DECLARATION
Policy / Certificate Number:   ……………..……………………..
Expiry Date:   …………..………………………..
I / We hereby declare that the current certificate of Motor insurance in respect
of the insured vehicle, Registration Number ……………………………..

delivered to Me / Us by the insurer in accordance with statutory requirements has become lost, mislaid or destroyed and I / We request the Insurer to issue a duplicate.

(Delete as necessary e.g. where there has been a change of car)

I / We undertake to return the missing certificate if found prior to expiry date.

I / We understand that 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 finish a Statutory Declaration relating to the loss or destruction of the Certificate.

Signed: 		 ……………………………………

Date:                                                 		……………………………………

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