Date of birth:
I confirm that the policy to which the certificate relates has ceased to have effect as from the date and time below.
The use of this form means that your policy is cancelled. It will be deleted from the Motor Insurance Database which is used by the police to enforce the law on insurance and if you use your vehicle without a valid policy, you will be committing an offence.
The declaration must be submitted to the insurer or the insurer�s appointed agent within seven days of the cancellation date. Failure to comply with this requirement is an offence under section 147 of the Road Traffic Act 1988.