Commercial Vehicle Insurance Quotation Details
Code (For Office Use Only)
Details taken by
Niall
Amanda
Mark
Sharon
Gerry
Ann Marie
Phone or Counter Call
Phone
Customer in the Office
Date & Time Capture
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Date
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Minutes
AM
PM
AM/PM Option
Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Company Name
Business Type/Occupation
*
Are you VAT registered
*
Yes
No
Address
*
Address Line 1
Address Line 2
City/Town
County
Eircode
Email Address
*
Phone Number
*
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Next
Main Driver Details
Is the Proposer & Main Driver the same person?
*
Yes
No
Licence Type
*
Full Irish
Provisional Irish
Full UK
Full EU
Other
Number of years Licence held
*
Driving Type on Policy
*
Insured Only
Named Drivers
Open Driving
Do you wish to name additional drivers
Yes
No
How Many additional drivers do you wish to add
1
2
3
4
5
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Additional Driver Details
Driver 2 Name
*
Date of Birth
*
/
Day
/
Month
Year
Occupation
*
Licence Type
*
Full Irish
Provisional Irish
Full UK
Full EU
Other
Number of years Licence Held
*
Driver 3 Name
*
Date of Birth
*
/
Day
/
Month
Year
Occupation
*
Licence Type
*
Full Irish
Provisional Irish
Full UK
Full EU
Other
Number of years Licence Held
*
Driver 4 Name
*
Date of Birth
*
/
Day
/
Month
Year
Occupation
*
Licence Type
*
Full Irish
Provisional Irish
Full UK
Full EU
Other
Number of years Licence Held
*
Driver 5 Name
*
Date of Birth
*
/
Day
/
Month
Year
Occupation
*
Licence Type
*
Full Irish
Provisional Irish
Full UK
Full EU
Other
Number of years Licence Held
*
Driver 6 Name
*
Date of Birth
*
/
Day
/
Month
Year
Occupation
*
Licence Type
*
Full Irish
Provisional Irish
Full UK
Full EU
Other
Number of years Licence Held
*
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Next
Previous Claims / Accidents / Penalty Points details for all drivers
Have you or any named drivers had any accidents or claims in the past 5 years
*
Yes
No
Past 5 Years Claims Details
Driver Name
Date of incident
Details of Incident
Settled or O/S
Amount settled for
Claim 1
Claim 2
If there was a claim - Was the No Claims Bonus Protected or Reduced
Protected
Stepped Back
Lost Bonus
Do you or any driver have any Penalty Points
*
Yes
No
Have you or any driver ever had any motoring or non motoring convictions
*
Yes
No
Have you or any driver ever had insurance refused, policy cancelled or special terms imposed
*
Yes
No
If yes to any of the above please provide full details
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Next
Vehicle Details
Registration Number
*
Make
*
Model
*
Is the vehicle a crew cab
*
Yes
No
Engine Size CC
*
Vehicle Value
*
Date of purchase
*
/
Day
/
Month
Year
Is the vehicle standard right hand drive
*
Yes
No
Is there any modifications to the vehicle
*
Yes
No
Is the vehicle registered in your name or a Ltd company name
*
Private name
Ltd Company name
Use of Vehicle
*
Social Domestic & Pleasure
Business Use
Other
Is the vehicle used only in relation to your business and for no other use
*
Yes
No
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Next
Current Cover Details
Who is your current insurer
*
Renewal Date
*
-
Day
-
Month
Year
What cover would you like
*
Comprehensive
Third Party Fire & Theft
Third Party Only
What type of bonus protection do you currently have
*
Full NCB Protection
Step Back
None
How many years no claims bonus are you entitled to
*
1
2
3
4
5+
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Next
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*
I Consent
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*
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Post
Phone
SMS
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