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Heffernan Insurances

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Lo-Call: 1890 333 400
Email: insurance@heffernan.ie

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Details of Motor Insurance Cover Personal Details     First Name *:   Surname *:   Address *:   Phone Number *:   (day) Phone Number *:   (evening)       Fax:   Email *:   Preferred method of contact:   phone   e-mail post Sex:   Male Female What is your date of birth *:   dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 mm Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec yyyy 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Have you ever held a motor policy in your own name?     Yes No If Yes, Name of Insurance Company:   Have you ever been a named driver   Yes No If Yes, On whose policy   For how many years   License type   Full Provisional Number of years license held *:   Occupation *:         Annual Mileage *:   Insurance Details     Type of cover required:   Comprehensive Third pary, fire and theft How many years no claims bonus in your own name?:   None 1 2 3 4 5 5+ Include protection for no claims bonus?:   Step back Bonus Protection Number of drivers:   0 1 2 3 4 Insured Only Insured and Named Open Driving Area in which you work *:   Have you ever been involved in any accidents?   Yes No If yes, please give details:   Have you ever made a claim on any motor policy?   Yes No If yes, please give details:   Have you ever been convicted of any motoring offence?   Yes No If yes, please give details:         Named Driver(s): If named driver(s) are required please give the following information: Named Driver 1: Name *:   Relation to insured *:   Occupation *:   Date of Birth:   dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 mm Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec yyyy 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Licence Type:   Full Provisional Sex:   Male Female Ever held your own insurance *:   What insurance company *:   How many years no claims bonus *:   Have they ever been involved in any accidents:   Yes No If yes, please give details:   Have they ever made a claim on any motor policy:   Yes No If yes, please give details:   Have they ever been convicted of any motoring offence:   Yes No If yes, please give details:   Named Driver 2:     Name:   Relation to insured:   Occupation *:   Date of Birth:   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Licence Type:   Full Provisional Sex:   Male Female Ever held your own insurance:   What insurance company:   How many years no claims bonus:   Have they ever been involved in any accidents:   Yes No If yes, please give details:   Have they ever made a claim on any motor policy:   Yes No If yes, please give details:   Have they ever been convicted of any motoring offence:   Yes No If yes, please give details:         Vehicle Details :     Vehicle Manufacturer *:   Model *:   Vehicle CC *:   Year of registration:   1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Value of vehicle:   Include windscreen cover:   Yes No Area vehicle is normally kept *:   Area vehicle is normally used *:   Is an alarm fitted to vehicle?   Yes No Annual Mileage:   5,000 6,000 7,000 8,000 9,000 10,000 11,000 12,000 13,000 14,000 15,000 16,000 17,000 18,000 19,000 20,000 21,000 22,000 23,000 24,000 25,000 Other Information :     Where did you hear about us?   * - indicates a required field

Heffernans, 35 Morgan Street, Waterford. Lo-Call: 1890 333 400 Email: insurance@heffernan.ie
Heffernan Insurances and Investments Ltd. t/a Heffernan Insurances, Heffernan Mortgage Solutions is regulated by the Financial Regulator. (Company No.: 134974)