Single HGV Enquiry

Code (For Office Use Only)

Details taken by

Phone or Counter Call

PhoneCustomer in the Office

Date

Hour Minutes

Proposer/Company Name *

Address*

Address Line 1

Address Line 2

City/TownCounty

Eircode

Phone Number*

Email*

example@example.com

Number of Years In Business*

Full Business Description*

Example: General Dry Groupage

Vehicle Details *

Rows	Vehicle Details
Make
Model
Reg Number
Gross Vehicle Weight
Carrying Capacity
Vehicle Value
Vehicle Signage
Vehicle Crane/Grab

Level of Cover Required *

Windscreen Cover *

Bonus Protection *

Drivers Required *

Territorial Limits *

Hazardous Goods Carried *

Main Drivers Details *

Rows	Details of Main Driver
Full Name
Date of Birth
Occupation
Full or Provisional Licence
Any Accidents, Claims, Convictions or Penalty Points

Earned NCB &/Or Named Driving Experience *

Rows	Number of Years	Type of Vehicle
Number Of Years No Claims Bonus
Driving Experience
Total of Both Driving & NCB

Renewal/Cover Date *

Date

Current Insurer *

Please Provide Details of Any Claims or Incidents in the last 5 Years *

Date, Claims Amount, Settled or Outstanding

Any Additional Information

Do you require Carrier's Liability cover?*

YesNo

Description of All Goods Carried *

Max Value Any One Load *

Value in €

Name of current Insurer *

If no previous insurance use N/A

Date Cover is Required*

Any Claims in the last 5 Years *

Details of any claims

Do you require Combined Liability Cover?*

YesNo

Public Liability Limit Required *

Turnover € for the last 12 months *

Employers Liability Limit Required*

Employees Details

Rows	Annual Wages
Drivers
Clerical Staff
Store Person

Any Public or Employer Liability Claims In The Last 5 Years *

Details of Any Public or Employers Liability Claims in the Last 5 Year if applicable

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 consentI do not consent

Please confirm we can contact you by email, telephone, SMS or post with quotations or in respect of any policy you hold with us*

EmailTelephonePostText Message

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 consentI do not consent

Single HGV Enquiry

To obtain you a Quotation we need your Consent

Contact Preference

Marketing Consent