Combined Liability Questions
Code (For Office Use Only)
Details taken by
Please Select
Niall
Mark
Sharon
Gerry
Ieva
Phone or Counter Call
Phone
Customer in the Office
Date & Time Capture
/
Day
/
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name
*
First Name
Last Name
Company Name/Trading Name
*
Address
*
Address Line 1
Address Line 2
City/Town
County
Eircode
Email
*
example@example.com
Phone Number
*
Mobile or Landline
Full Business Description
*
Example: Builder, Ground works
Do You Do Standalone Roofing Contracts
*
Please Select
Yes
No
If Yes What % of your business is standalone roofing
Number of Years In Business
*
Number of Years Experience in this Trade
Please Select
Less Than 1 Year
1 Year
2 Years
3 Years
4 Years
5 Years
5+ Years
Are You A Member of
*
Please Select
CIF
CIRI
N/A
Public/Products Liability Limit of Indemnity
*
Please Select
€1,300,000
€2,600,000
€6,500,000
Gross Annual Turnover
*
in €
Is Employers Liability Cover Required
*
Please Select
Yes
No
Employers Liability Limit Of Indemnity
Please Select
13,000,000
Employers Liability
Rows
Number of Employees
Gross Annual Wages
Manual Working Directors
Clerical Working Directors
Manual Employees
Clerical Employees
Laborer Only Sub Contractors
Bona-Fida Sub Contractors
General Manager
Duty Manager
Cleaner
Security Staff
Chefs
Height Limit Required
*
Please Select
15 Meters
25 Meters
Unrestricted
N/A
Depth Limit Required
Please Select
N/A
0.5 Metre
1 Metre
2 Metres
3 Metres
4 Metres
5 Metres
Do You Work in any of the following locations
Rows
Required
% Amount
Agriculture
Yes
No
Mines
Yes
No
Quarry’s
Yes
No
Industrial
Yes
No
Commercial Buildings
Yes
No
Domestic Buildings
Yes
No
Refugee Centre
Yes
No
Territorial Limits
*
Rows
% Breakdown Of Each
Ireland Only
Ireland/UK
Rest of the World
Name of Current Insurance Company
Renewal Date/Inception Date
Any Claims in the Last 5 years
*
Please Select
Yes
No
Details of Claims in the last 5 years
Any Additional Information
How Did You Hear About Us
*
Please Select
Facebook
Google Search
Referral
Radio Add
Existing Customers
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 National Insurance. Please choose below
*
I consent
I do not consent
Click here to submit your details
Should be Empty: