SECTION 1: Proposer Details
Title
Mr
Ms
Mrs
Miss
Dr
Fr
First Name
Last Name
Gender
Male
Female
Date of Birth
Marital Status
Married
Single
Comon Law
Separated
Divorced
Widowed
Select
Main Address
E.Mail
Contact Telephone No
Mobile Phone No
SECTION 2: Previous or Current Insurance
Do you currently have motor insurance in your own name
Yes
No
Select
If you answered ‘Yes’ to the above name of Insurer
No Claims Discount
1 Year
2 Years
3 Years
4 Years
5 Years
Select
Expiry Date
Were you previously Insured in your own name
Yes
No
Select
When did this Insurance expire
If not in Ireland - Country you held Insurance
SECTION 3: Additional Driver Details: If there are no additional drivers go to Section 4
Driver 1:
First Name
Last Name
Gender
Relationship to Proposer
Select
Spouse
Other
If ‘Other’ please give details
Address if different from the Proposers
Date of Birth
Occupation
Employers Business
Type of Licence
Full Irish
Full U.K.
Provisional
E.U.
International
Select
Licence Issued
Are there any Penalty Points on the Licence
Select
Yes
No
If ‘Yes’ to the above please give details of the offence
Any convictions
Select
Yes
No
If ‘Yes’ to the above please give details of the offence
Claims within the past 5 years
Select
Yes
No
If ‘Yes’ to the above please give details
Prosecutions Pending
Select
Yes
No
If ‘Yes’ to the above please give details
Any Medical Conditions we should be aware of
Select
Yes
No
If ‘Yes’ to the above please give details
Driver 2:
First Name
Last Name
Gender
Relationship to Proposer
Address if different from the Proposers
Date of Birth
Occupation
Employers Business
Type of Licence
Full Irish
Full U.K.
Provisional
E.U.
International
Select
Licence Issued
Are there any Penalty Points on the Licence
Select
Yes
No
If ‘Yes’ to the above please give details of the offence
Any convictions
Select
Yes
No
If ‘Yes’ to the above please give details
Claims within the past 5 years
Select
Yes
No
If ‘Yes’ to the above please give details
Prosecutions Pending
Select
Yes
No
If ‘Yes’ to the above please give details
Any Medical Conditions we should be aware of
Select
Yes
No
If ‘Yes’ to the above please give details
Driver 3:
First Name
Last Name
Gender
Relationship to Proposer
Address if different from the Proposers
Date of Birth
Occupation
Employers Business
Type of License
Full Irish
Full U.K.
Provisional
E.U.
International
Select
License Issued
Are there any Penalty Points on the Licence
Select
Yes
No
If ‘Yes’ to the above please give details of the offence
Any convictions
Select
Yes
No
If ‘Yes’ to the above please give details
Claims within the past 5 years
Select
Yes
No
If ‘Yes’ to the above please give details
Prosecutions Pending
Select
Yes
No
If ‘Yes’ to the above please give details
Any Medical Conditions we should be aware of
Select
Yes
No
If ‘Yes’ to the above please give details
Driver 4:
First Name
Last Name
Gender
Relationship to Proposer
Address if different from the Proposers
Date of Birth
Occupation
Employers Business
Type of License
Full Irish
Full U.K.
Provisional
E.U.
International
Select
License Issued
Are there any Penalty Points on the Licence
Select
Yes
No
If ‘Yes’ to the above please give details of the offence
Any convictions
Select
Yes
No
If ‘Yes’ to the above please give details
Claims within the past 5 years
Select
Yes
No
If ‘Yes’ to the above please give details
Prosecutions Pending
Select
Yes
No
If ‘Yes’ to the above please give details
Any Medical Conditions we should be aware of
Select
Yes
No
If ‘Yes’ to the above please give details
SECTION 4: Other Claim Free Driving Experience
Type
Full time company car experience
Named driver experience
Part time company car experience
Years
Insurer
Country
Relationship to Policy Holder
Spouse
Parent
Sibling
Partner
Employer
Other
Select
If ‘Other’ to the above, please give details
SECTION 5: Your Occupation
Full Time Occupation
Part Time Occupation
Employers Business
Employment Status
Director
Proprietor
Self-Employed
Employee
Unemployed
Retired
Household Duties
Select
SECTION 6: License Details
Type
Full Irish
Full UK
Provisional
EU
International
Other
Select
If ‘Other’ to the above, please give details
Licence Issued
Penalty Points
Yes
No
Select
If ‘Yes’ to the above, how many
Penalty Points - details of offence
Any Convictions
Yes
No
Select
If ‘Yes’ to the above, please give details
Claims within the past 5 years
Yes
No
Select
If ‘Yes’ to the above, please give details
Prosecutions Pending
Yes
No
Select
If ‘Yes’ to the above, please give details
Any Medical Conditions we should be aware of
Yes
No
Select
If ‘Yes’ to the above, please give details
SECTION 7: Vehicle Details
Make and Model... eg. Ford Escort
Exact Model eg GL, DL, etc
Registered Date
Registration Number
Registered in Ireland
Yes
No
Select
If ‘No’ to the above, please state country of origin
CC - Cubic Capacity
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
Select
Vehicle Body Type
Saloon
Hatchback
Estate
Coupe
Convertible
Van
Jeep
Select
Model
Manual
Automatic
Select
Present estimated value
Left Hand Drive
Yes
No
Select
Imported
Yes
No
Select
Has the vehicle been modified in any way
Yes
No
Select
If ‘Yes’ to the above, please give details
Security
Alarm
Alarm and Immobilizer
Alarm and Tracker
Alarm, Immobilizer and Tracker
Immobilizer and Tracker
None
Select
Registered Owner
Proposer
Vehicle Lease
Parent
Spouse
Sibling
Other Relative
Unrelated Third Party
Employer
Select
If you are ‘not’ the Registered Owner p lease give details
Area of main use
Area kept overnight
Overnight Parking
Private Property
Driveway
Garaged
Public Highway
Select
Average Private Miles per annum
SECTION 8: Cover and Use Details
Cover Required
Comprehensive
Third Party Fire & Theft
Third Party Only
Third Party Fire & Theft + Windscreen Cover
Third Party Fire & Theft + Legal Protection
Third Party Fire & Theft + Windscreen & Legal
Select
Class of Use
Social, Domestic and Pleasure
Class 1
Class 2
Class 3
Select
Driver Details
Insured Only
Insured and Spouse only
Insured and 1 named driver
Insured and 2 named drivers
Insured and 3 named drivers
Insured and 4 named drivers
Insured and 5 named drivers
Open Driving 25 years to 70 years
Select
No Claims Discount Protection
Full
None
Partial
Step Back
Select
Start Date
Have you completed the Hibernian Ignition Course
Yes
No
Select
If ‘Yes’ please quote your Reference Number
Any other information you feel we should be aware of
