Motor Trade Insurance Online Quotation Details

Code (For Offices Use Only)

Phone or Counter Call

PhoneCustomer in Office

The following details has been captured by one of our brokers with you over the phone.

The following details have been captured by one of our brokers with you in our office.

Broker Name

Time Captured

Date Captured

Motor Trade Insurance - Details for Quotation

Your Name (Proposer)

Your Date of Birth

Company Name

Address

Street Address

Street Address Line 2

CityCounty

Eircode

Is this your

Your Mobile Number

Email

example@example.com

Are You Registered for VAT

Please provide a full business description of the services you provide

Are You Full or Part-Time

Full TimePart-Time

If Part Time please state Full Time Occupation

Please provide us with a list of how you advertise your business

As you are Part Time and Non VAT registered please note that you will need to provide proof of trading.

Please provide a breakdown as a percentage of each type of business you provide

	Percentage of your Work
Car & Van Sales
Car & Van Repairs / Servicing
Heavy Goods Vehicle Sales
Heavy Goods Vehicle Repairs / Servicing
Motor Bike Sales / Servicing
Autoelectrican
Panel Beater / Crash Repairs
Tyre / Exhaust Fittier
Windscreen Fitter
Valeter
Vehicle

What percentage of your work is away from your premises? (Aside from Car Sales)

Do you own a recovery truck

Please give details of recovery truck and services offered

Do you require cover for Motorbikes?

Main Driver (Proposer Details)

Date of Birth

Main Driver Licence Type

How long have you held licence (years)

Any Penalty Points

Number of Points

Details of dates / reason / number of points received

Any previous claims in the last 5 years.

How many additional drivers do you want to add to your policy?

Additional Driver 1

Additional Driver 1 Name

Type of Cover for Driver 1

Driver 1 Relationship to the Proposer

If Other please advise

Additional Driver 1 Date of Birth

Additional Driver 1 Licence Type

Additional Driver 1 - How long have they held licence

Additional Driver 1 Any Penalty Points

Additional Driver 1 Number of Points

Additional Driver 1 Details of dates / reason / number of points received

Additional Driver 1 Any previous claims in the last 5 years.

Additional Driver 2

Additional Driver 2 Name

Type of Cover for Driver 2

Driver 2 Relationship to the Proposer

If Other please advise

Additional Driver 2 Date of Birth

Additional Driver 2 Licence Type

Additional Driver 2 - How long have they held licence

Additional Driver 2 Any Penalty Points

Additional Driver 2 Number of Points

Additional Driver 2 Details of dates / reason / number of points received

Additional Driver 2 Any previous claims in the last 5 years.

Additional Driver 3

Additional Driver 3 Name

Type of Cover for Driver 3

Driver 3 Relationship to the Proposer

If Other please advise

Additional Driver 3 Date of Birth

Additional Driver 3 Licence Type

Additional Driver 3 - How long have they held licence

Additional Driver 3 Any Penalty Points

Additional Driver 3 Number of Points

Additional Driver 3 Details of dates / reason / number of points received

Additional Driver 3 Any previous claims in the last 5 years.

Additional Driver 4

Additional Driver 4 Name

Type of Cover for Driver 4

Driver 4 Relationship to the Proposer

If Other please advise

Additional Driver 4 Date of Birth

Additional Driver 4 Licence Type

Additional Driver 4 - How long have they held licence

Additional Driver 4 Any Penalty Points

Additional Driver 4 Number of Points

Additional Driver 4 Details of dates / reason / number of points received

Additional Driver 4 Any previous claims in the last 5 years.

Additional Driver 5

Additional Driver 5 Name

Type of Cover for Driver 5

Driver 5 Relationship to the Proposer

If Other please advise

Additional Driver 5 Date of Birth

Additional Driver 5 Licence Type

Additional Driver 5 - How long have they held licence

Additional Driver 5 Any Penalty Points

Additional Driver 5 Number of Points

Additional Driver 5 Details of dates / reason / number of points received

Additional Driver 5 Any previous claims in the last 5 years.

Claims Details

Please record details of any claims for each driver in the last 5 years

	Driver Name	Date	Accident Type	Accident Status	Reserve / Paid	Details of what happened
1
2
3
4
5

Current Insurance Details

Do you currently hold motor trade insurance

Present Insurer

Renewal Date

Bonus Type

How many years Bonus

Cover Required

The number of vehicles owned and registered by You (the proposer) or company?

Any other relevant information

Where did you hear about us?

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EmailPostPhoneSMS

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