Motor Trade Insurance Online Quote | National Insurance Ltd

Motor Trade Enquiry Form
Code (For Office Use Only)
Details taken by
Phone or Counter Call

PhoneCustomer in the Office
Date & Time Capture

DayMonthYear
Date
Hour Minutes
Customers Name *
Trading Name/Limited Company Name if Applicable
Address*

Address Line 1

Address Line 2

City/TownCounty

Eircode
Is the Risk Address different than the Home address*
Risk Address

Address Line 1

Address Line 2

City/TownCounty

Eircode
Are You Registered for Vat or Registered with Revenue as a Motor Trade Business *
Contact Number*
Customer Email*
example@example.com

% Breakdown in your business activities *

	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 TimePart TimeFull 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 LicenceFull UK LicenceFull EU LicenceProvisional LicenceOther
How Many Years Held: *
Bonus Type*
Number of years claims free experience:*
Max Gross Vehicle Weight: *
Own Or Deal in any Modified, High Performance or Classic Vehicles: A FULL LIST OF THE CLIENTS VEHICLES ARE REQUIRED IN THE BOX BELOW*

YesNo
Do you Own Any Recovery Vehicles:*

YesNo

Own or work on Motor Cycles:*

YesNo

Experience/Qualified
Ever Held A PSV Licence (Taxi Licence)

YesNo
Cover*
Additional Drivers:*

YesNo
How Many Additional Drivers do you require
Additional Driver 1 Name
Additional Driver 1 Date of Birth
Occupation
Additional Driver 1 Licence Type

Full IrishProvisional IrishFull UKFull EUOther
Use Required
Additional Driver 2 Name
Additional Driver 2 Date of Birth
Occupation
Additional Driver 2 Licence Type

Full IrishProvisional IrishFull UKFull EUOther
Use Required
Additional Driver 3 Name
Additional Driver 3 Date of Birth
Occupation
Additional Driver 3 Licence Type

Full IrishProvisional IrishFull UKFull EUOther
Use Required
Additional Driver 4 Name
Additional Driver 4 Date of Birth
Occupation
Additional Driver 4 Licence Type

Full IrishProvisional IrishFull UKFull EUOther
Use Required
Additional Driver 5 Name
Additional Driver 5 Date of Birth
Occupation
Additional Driver 5 Licence Type

Full IrishProvisional IrishFull UKFull EUOther
Use Required
Additional Driver 6 Name
Additional Driver 6 Date of Birth
Occupation
Additional Driver 6 Licence Type

Full IrishProvisional IrishFull UKFull EUOther
Use Required
Has any driver ever had any Accidents/Claims/Convictions(motoring & Non-motoring):*

YesNo
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
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 consentI 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*

EmailTelephonePostText 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 Campion Insurance. Please choose below*

I consentI do not consent
Should be Empty:

	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

	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

Motor Trade Enquiry Form

To obtain you a Quotation we need your Consent

Contact Preference

Marketing Consent