Request for Temporary Protective Screen in a
Private Hire or Hackney Carriage Vehicle
Vehicle Registration Number
Vehicle Licence Number
(tick as appropriate)
PHV
HCV
Vehicle Proprietors Name
Daytime Contact Telephone No.
Make or Model of Temporary
Protective Screen
I have attached/included, confirmation, from my Insurance Company, of
continuing valid Vehicle Insurance following the installation of a Temporary
Protective Screen in my vehicle.
Please now complete the declaration below.
I ………………………………………………………. (Name of Driver)
Confirm that I will ensure the Temporary Protective Screen installed in the
above vehicle during the coronavirus outbreak will be regularly maintained
and sanitised and will be removed from my vehicle in less than 21 days after
social distancing restrictions relating to COVID-19 have been removed.
Signed: ………………………………………………………………….
Date: ………………………………………………………………
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