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 *

	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 *

	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 *

	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

	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

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Single HGV Enquiry

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