MOTOR INSURANCE QUOTATION WITHIN ONE WORKING DAY

Let us provide you with a Quotation  (not a ‘guestimate’)  within one working day
  Simply complete the Proposal Form below and based on the information you supply we will search for the most suitable cover  to match your requirements

SECTION 1:  Proposer Details

Title

Mr Ms Mrs Miss Dr Fr

First Name

Last Name

Gender

Male Female

Date of Birth

Marital Status

Married Single Comon Law Separated Divorced Widowed Select

Main Address

E.Mail

Contact Telephone No

Mobile Phone No

SECTION 2:  Previous or Current Insurance

Do you currently have motor insurance in your own name

Yes No Select

If you answered ‘Yes’ to the above name of Insurer

No Claims Discount

1 Year 2 Years 3 Years 4 Years 5 Years Select

Expiry Date

Were you previously Insured in your own name

Yes No Select

When did this Insurance expire

If not in Ireland - Country you held Insurance

SECTION 3:  Additional Driver Details:             If there are no additional drivers go to Section 4     

Driver 1:

First Name

Last Name

Gender

Relationship to Proposer

Select Spouse Other

If ‘Other’ please give details

Address if different from the Proposers

Date of Birth

Occupation

Employers Business

Type of Licence

Full Irish Full U.K. Provisional E.U. International Select

Licence Issued

Are there any Penalty Points on the Licence

Select Yes No

If ‘Yes’ to the above please give details of the offence

Any convictions

Select Yes No

If ‘Yes’ to the above please give details of the offence

Claims within the past 5 years

Select Yes No

If ‘Yes’ to the above please give details

Prosecutions Pending

Select Yes No

If ‘Yes’ to the above please give details

Any Medical Conditions we should be aware of

Select Yes No

If ‘Yes’ to the above please give details

Driver 2:

First Name

Last Name

Gender

Relationship to Proposer

Address if different from the Proposers

Date of Birth

Occupation

Employers Business

Type of Licence

Full Irish Full U.K. Provisional E.U. International Select

Licence Issued

Are there any Penalty Points on the Licence

Select Yes No

If ‘Yes’ to the above please give details of the offence

Any convictions

Select Yes No

If ‘Yes’ to the above please give details

Claims within the past 5 years

Select Yes No

If ‘Yes’ to the above please give details

Prosecutions Pending

Select Yes No

If ‘Yes’ to the above please give details

Any Medical Conditions we should be aware of

Select Yes No

If ‘Yes’ to the above please give details

Driver 3:

First Name

Last Name

Gender

Relationship to Proposer

Address if different from the Proposers

Date of Birth

Occupation

Employers Business

Type of License

Full Irish Full U.K. Provisional E.U. International Select

License Issued

Are there any Penalty Points on the Licence

Select Yes No

If ‘Yes’ to the above please give details of the offence

Any convictions

Select Yes No

If ‘Yes’ to the above please give details

Claims within the past 5 years

Select Yes No

If ‘Yes’ to the above please give details

Prosecutions Pending

Select Yes No

If ‘Yes’ to the above please give details

Any Medical Conditions we should be aware of

Select Yes No

If ‘Yes’ to the above please give details

Driver 4:

First Name

Last Name

Gender

Relationship to Proposer

Address if different from the Proposers

Date of Birth

Occupation

Employers Business

Type of License

Full Irish Full U.K. Provisional E.U. International Select

License Issued

Are there any Penalty Points on the Licence

Select Yes No

If ‘Yes’ to the above please give details of the offence

Any convictions

Select Yes No

If ‘Yes’ to the above please give details

Claims within the past 5 years

Select Yes No

If ‘Yes’ to the above please give details

Prosecutions Pending

Select Yes No

If ‘Yes’ to the above please give details

Any Medical Conditions we should be aware of

Select Yes No

If ‘Yes’ to the above please give details

SECTION 4:  Other Claim Free Driving Experience

Type

Full time company car experience Named driver experience Part time company car experience

Years

Insurer

Country

Relationship to Policy Holder

Spouse Parent Sibling Partner Employer Other Select

If ‘Other’ to the above, please give details

SECTION 5:   Your Occupation

Full Time Occupation

Part Time Occupation

Employers Business

Employment Status

Director Proprietor Self-Employed Employee Unemployed Retired Household Duties Select

SECTION 6:  License Details

Type

Full Irish Full UK Provisional EU International Other Select

If ‘Other’ to the above, please give details

Licence Issued

Penalty Points

Yes No Select

If ‘Yes’ to the above, how many

Penalty Points - details of offence

Any Convictions

Yes No Select

If ‘Yes’ to the above, please give details

Claims within the past 5 years

Yes No Select

If ‘Yes’ to the above, please give details

Prosecutions Pending

Yes No Select

If ‘Yes’ to the above, please give details

Any Medical Conditions we should be aware of

Yes No Select

If ‘Yes’ to the above, please give details

SECTION 7:   Vehicle Details

Make and Model... eg. Ford Escort

Exact Model eg    GL, DL, etc

Registered Date

Registration Number

Registered in Ireland

Yes No Select

If ‘No’ to the above, please state country of origin

CC - Cubic Capacity

800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 Select

Vehicle Body Type

Saloon Hatchback Estate Coupe Convertible Van Jeep Select

Model

Manual Automatic Select

Present estimated value

Left Hand Drive

Yes No Select

Imported

Yes No Select

Has the vehicle been modified in any way

Yes No Select

If ‘Yes’ to the above, please give details

Security

Alarm Alarm and Immobilizer Alarm and Tracker Alarm, Immobilizer and Tracker Immobilizer and Tracker None Select

Registered Owner

Proposer Vehicle Lease Parent Spouse Sibling Other Relative Unrelated Third Party Employer Select

If you are ‘not’ the Registered Owner please give details

(Name) (Address)

Area of main use

Area kept overnight

Overnight Parking

Private Property Driveway Garaged Public Highway Select

Average Private Miles per annum

SECTION 8:  Cover and Use Details

Cover Required

Comprehensive Third Party Fire & Theft Third Party Only Third Party Fire & Theft + Windscreen Cover Third Party Fire & Theft + Legal Protection Third Party Fire & Theft + Windscreen & Legal Select

Class of Use

Social, Domestic and Pleasure Class 1 Class 2 Class 3 Select

Driver Details

Insured Only Insured and Spouse only Insured and 1 named driver Insured and 2 named drivers Insured and 3 named drivers Insured and 4 named drivers Insured and 5 named drivers Open Driving 25 years to 70 years Select

No Claims Discount Protection

Full None Partial Step Back Select

Start Date

Have you completed the Hibernian Ignition Course

Yes No Select

If ‘Yes’ please quote your Reference Number

Any other information you feel we should be aware of