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Motor Insurance Enquiry
YOU THE PROPOSER
Name Email Address Phone Day Phone Evening
Area of Main Use :- Date of Birth    
   

THE VEHICLE
Reg No. :- Make / Model:- Engine cc :- Year :- Value :- Purchase Date :- Annual Mileage :- LHD :-

The Vehicle has not been modified or converted in any way :- The Vehicle is not fitted with a security device :-
The Vehicle is not fitted with any non standard audio equipment :- The Vehicle is not fitted with a car phone :-
The Owner of the Vehicle is:- The Vehicle is registered in the name of:-

The Vehicle is normally kept by me at :-

DRIVERS OF YOUR VEHICLE
Name Sex Date of Birth Relationship to Proposer Occupation Employers Business Licence Type Years Held Non Drinker

DRIVERS /CLAIMS HISTORY
Other than as specified below, neither I, my spouse nor any driver who will drive to the best of my knowledge or belief :
 1. suffer from defective vision, defective hearing, diabetes, epilepsy, heart condition or any other physical or mental infirmity or any any drug or alcohol related condition.
 2.  have been involved in ANY motor accidents or claims in the last 5 years.
 3. have ever had a motor proposal or renewal declined, had terms imposed or had a policy cancelled.
 4. have ever been convicted of a motoring offence, ever been disqualified or have any prosecutions pending.
 5. own, insure or have full time use of any other vehicle.
 6. have resided outside the Republic of Ireland, Northern Ireland or UK at any time during the last 5 years.

No Claims Discount Type Reason
the Insurer Is The Policy Expiry Date is The Policy No. is

ACCIDENTS /CLAIMS DETAILS
Driver Date Type Amount £ NCB Affected At Fault Settled Personal Injury

COVER AND USE
Cover Required Cover operational from Date Cover operational from Time
Class of Use Windscreen Cover Voluntary Excess Amount ( In addition to standard policy excess ) £
     

DRIVERS /SPOUSE WITH SECOND CAR DETAILS
Driver Make/Model Engine cc Insurer Policy No. Owner Main User