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

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Details of Commercial 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:  

What is your date of birth *:  


Have you ever held a motor policy in your own name?    

If Yes, Name of Insurance Company:  

Have you ever been a named driver  

If Yes, On whose policy  

For how many years  

License type  

Number of years license held *:  

Occupation *:  
     
     


Insurance Details

   
Type of cover required:  

How many years no claims bonus in your own name?:

 
Include protection for no claims bonus?:

 
Number of drivers:  

Area in which you work *:  

Have you ever been involved in any accidents?  
If yes, please give details:  

Have you ever made a claim on any motor policy?  
If yes, please give details:  

Have you ever been convicted of any motoring offence?  
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:  


Licence Type:  
Sex:  
Ever held your own insurance *:  

What insurance company *:  

How many years no claims bonus *:  

Have they ever been involved in any accidents:

 
If yes, please give details:  

Have they ever made a claim on any motor policy:

 
If yes, please give details:  

Have they ever been convicted of any motoring offence:

 
If yes, please give details:  

Named Driver 2:

   
Name:  
Relation to insured:  
Occupation *:  
Date of Birth:  
Licence Type:  
Sex:  
Ever held your own insurance:  

What insurance company:  

How many years no claims bonus:  

Have they ever been involved in any accidents:  
If yes, please give details:  
Have they ever made a claim on any motor policy:

 
If yes, please give details:  


Have they ever been convicted of any motoring offence:

 
If yes, please give details:  

     


Vehicle Details :

   
Vehicle Manufacturer *:  
Model *:  
Vehicle CC *:  
Year of registration:  
Value of vehicle:  
Include windscreen cover:  
Area vehicle is normally kept *:  
Area vehicle is normally used *:  
Is an alarm fitted to vehicle?  
Annual Mileage:  
Tonnage of vehicle:  


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 & Investments Limited t/a Heffernan Insurances, Heffernan Mortgage Solutions & Life Time Loans is regulated by the Central Bank of Ireland. (Company No.: 134974)