Motor Trade Enquiry Form
Code (For Office Use Only)
Details taken by
Please Select
Niall
Mark F
Lisa
Mark B
Rachel
Noelle
Phone or Counter Call
Phone
Customer in the Office
Date & Time Capture
/
Day
/
Month
Year
Date
Hour Minutes
Customers Name
*
Trading Name/Limited Company Name if Applicable
Email
*
example@example.com
Address
*
Address Line 1
Address Line 2
City/Town
County
Eircode
Is the Risk Address different than the Home address
*
Please Select
Yes
No
Risk Address
Address Line 1
Address Line 2
City/Town
County
Eircode
Are You Registered for Vat or Registered with Revenue as a Motor Trade Business
*
Please Select
Vat Registered
Registered with Revenue
Neither
Contact Number
*
% Breakdown in your business activities
*
Rows
Breakdown out of 100%
Servicing & Repairs of Cars & Light Commercials
Sales of Cars & Light Commercials
Sales/Repairs of Agri Vehicles
Sales/Repairs of HGV Vehicles
Recovery Services
Tyre Sales, Fitting & Repairs
Valeting
Car/Light Commercial Vehicle Breaking
Windscreen Fitter
Panel Beating/Crash Repairs
Auto Electrician
Mobile % if Required
Window Tinting/Sign Writing
Full Time or Part time in the Motor Trade:
*
Full Time
Part Time
Full Time Employed In the Motor Trade
If Part Time – What’s your other source of income:
Annual Turnover
*
Gross Turnover from Motor Trade Activites
Date of Birth
*
Licence Type
*
Full Irish Licence
Full UK Licence
Full EU Licence
Provisional Licence
Other
How Many Years Held:
*
Bonus Type
*
Please Select
Private Car
Commercial Vehicle
Motor Trade
Named Driving Experience
No Previous Insurance
Number of years claims free experience:
*
Please Select
0 years
1 years
2 years
3 years
4 years
5 years
6 years
6+ years
Max Gross Vehicle Weight:
*
Please Select
0-10 Ton
10-20Ton
20-30Ton
30-46Ton
Over 10Tonne
Current UID Number
Do You Own or Deal in any Modified, High Performance or Classic Vehicles: A FULL LIST OF THE CLIENTS VEHICLES ARE REQUIRED IN THE BOX BELOW
*
Yes
No
Full List of Vehicles Above
Do you Own Any Recovery Vehicles:
*
Yes
No
Recovery Truck Details
Rows
Recovery Truck 1
Recovery Truck 2
Recovery Truck 3
Make
Model
Gross Vehicle Weight
How Many can it carry
How many can it tow
Value €
REG/Year
Own or work on Motor Cycles:
*
Yes
No
Motor Cycle Details
Rows
Details
Is Business Use only required
Is Social Domestic & Pleasure Use only required
Is MT & Social Domestic Pleasure use required
Do you hold a full or provisional bike licence
Experience/Qualified
Please Select
Mechanic
Agri Mechanic
HGV Mechanic
Panel Beater
Valetor
Vehicle Sale
Apprentice Mechanic
Apprentice Panel Beater
N/A
Ever Held A PSV Licence (Taxi Licence)
Yes
No
Cover
*
Please Select
Comprehensive
Third Party Fire & Theft
Third Party Only
Additional Drivers:
*
Yes
No
List All Drivers
Has any driver ever had any Accidents / Claims / Convictions (motoring & Non-motoring):
*
Yes
No
Number of Penalty Points:
*
Present Insurer:
*
Renewal/Inception Date :
*
A LIST OF ALL VEHICLES OWNED BY THE INSURED:
*
Any additional information:
How Did You Hear About Us
Please Select
Hubspot
Facebook Add
Facebook MT Group
Google Search
Referral
Other
To obtain you a Quotation we need your Consent
In order to obtain you a quotation we need your permission to submit your details provided to insurers to obtain you a quotation
*
I give consent
I do not consent
Contact Preference
Please confirm we can contact you by email, telephone, SMS or post with quotations or in respect of any policy you hold with us
*
Email
Telephone
Post
Text Message
Marketing Consent
From time to time we may also send you communication in relation to other products or services we offer. We never share your email address with any other parties. Please confirm that it is OK to send you marketing information from Dolmen Insurance Brokers Ltd. Please choose below
*
I consent
I do not consent
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