Modified Vehicle Report Form

Subject to acceptance by the Company shown above, this form attaches to and forms part of the POLICY of INSURANCE. Please ensure that all questions are answered in full and returned to Brentacre.

Give FULL DETAILS of any modifications to the standard specification or components of the vehicle including for example, Alloy Wheels, Engine changes, Remaps, Paintwork, Decals and Interior changes. Please ensure you list every modification which makes your vehicle unique to factory specifications.

DECLARATION: I declare that to the best of my knowledge and belief all the above statements are true and complete. I understand that it is my duty to disclose all facts which are material to and will influence the acceptance and assessment of the vehicle, (if you are in any doubt about facts considered material, you should disclose them), and that failure to do so means that the policy may not operate to protect me. I agree that this form and declaration shall form part of the basis of the contract between me and the Insurer,and that if any answer has been written by any other person, such person shall be deemed to be my agent for that purpose.

PLEASE NOTE: Your vehicle must be road worthy. Any modifications must meet UK road regulations and pass an MOT if applicable. Any illegal modifications could invalidate your insurance.

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Brentacre™ Insurance Services Limited are registered in England and Wales (Companies House Number 02081054)
Registered at: Phoenix Way, Swansea, SA4 9WF
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