Declaration

I hereby certify that the information given in the form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I understand that this claim may be refused if information is untrue, inaccurate and concealed.

I authorise Wiggle Cycle Insurance to give to, or obtain from other insurers or any insurance reference bureau, any information relevant to this claim or any other claim made by me on any insurance policy held by me.