Motor Trade Enquiry Form
Code (For Office Use Only)
Details taken by
Please Select
Niall
Mark
Gerry
Noelle
Niamh
Rachel
John - Ollie Murphy’
Hugh - Campions
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
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
*
Customer Email
*
example@example.com
% 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
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
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
How Many Additional Drivers do you require
Additional Driver 1 Name
Additional Driver 1 Date of Birth
Occupation
Additional Driver 1 Licence Type
Full Irish
Provisional Irish
Full UK
Full EU
Other
Use Required
Please Select
Spouse SDP Only
Spouse MT/SDP
Driver MT Only
Driver MT/SDP
Bus Partner/Director
Additional Driver 2 Name
Additional Driver 2 Date of Birth
Occupation
Additional Driver 2 Licence Type
Full Irish
Provisional Irish
Full UK
Full EU
Other
Use Required
Please Select
Spouse SDP only
Spouse MT/SDP
Driver MT Only
Driver MT/SDP
Bus Partner/Director
Additional Driver 3 Name
Additional Driver 3 Date of Birth
Occupation
Additional Driver 3 Licence Type
Full Irish
Provisional Irish
Full UK
Full EU
Other
Use Required
Please Select
Spouse SDP Only
Spouse MT/SDP
Driver MT Only
Driver MT/SDP
Bus Partner/Director
Additional Driver 4 Name
Additional Driver 4 Date of Birth
Occupation
Additional Driver 4 Licence Type
Full Irish
Provisional Irish
Full UK
Full EU
Other
Use Required
Please Select
Spouse SDP Only
Spouse MT/SDP
Driver MT Only
Driver MT/SDP
Bus Partner/Director
Additional Driver 5 Name
Additional Driver 5 Date of Birth
Occupation
Additional Driver 5 Licence Type
Full Irish
Provisional Irish
Full UK
Full EU
Other
Use Required
Please Select
Spouse SDP Only
Spouse MT/SDP
Driver MT Only
Driver MT/SDP
Bus Partner/Director
Additional Driver 6 Name
Additional Driver 6 Date of Birth
Occupation
Additional Driver 6 Licence Type
Full Irish
Provisional Irish
Full UK
Full EU
Other
Use Required
Please Select
Spouse SDP Only
Spouse MT/SDP
Driver MT Only
Driver MT/SDP
Bus Partner/Director
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
Facebook
Facebook Motor Trade Group
Google Search
Referral
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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
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Email
Telephone
Post
Text Message
Marketing Consent
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