Car Insurance Quote

Quote Form

Please take 50 seconds to complete the following form to receive a tailored quotation for your car insurance.

Required fields are marked with *

Your Details

  • First Name *
  • Surname *
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  • Address *
  • Address 2
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  • Town / City
  • County *
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  • Date of Birth *
  • Telephone
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  • Gender
  • Mobile
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  • Driving Licence Held *
  • Email *
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  • Date Obtained *
  • Country Obtained *
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  • Occupation *
  • Employer's Business *
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  • How Many Years are you Resident in Ireland *
  • Do you have any medical conditions
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  • Name of Medical condition
  • Date Diagnosed
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  • Is Licencing Authority aware of same
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  • Do you have any convictions
  • What for
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  • Date
  • Disqualified?
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  • How long for?
  • Have you ever had an insurance policies declined or cancelled on you?
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Additional Named Driver Details (If Required)

  • Full Name
  • Gender
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  • Date Of Birth
  • Relationship To Proposer
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  • Reside with Proposer (Yes/No)
  • How Long Resident In Ireland
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  • Occupation
  • Driving Licence Held
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  • Date Licence First Issued
  • Country Obtained
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  • Claims History
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Current Insurance Details (If Any)

  • Car Registration *
  • Car Value (€) *
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  • Car Imported (Yes/No) *
  • Car Modified (Yes/No) *
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  • Where is Car parked at Night *
  • Security *
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  • Name of Current Insurance Company *
  • How many years no claims discount do you have ? *
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  • Current Premium
  • Named Driving Experience (Years)? *
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  • Relationship to Policyholder
  • Name of Insurance company
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  • Date of Expiry
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  • Class of Use *
  • Cover Required *
  • Renewal Date *
  • 2nd Car in Family (Yes/No)
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  • Do you have any Penalty Points (Yes/No)
  • If Yes, How Many?
  • Offence?
  • Date they were applied to your licence?
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2nd Car Details

  • Registration Number
  • Who’s name is the vehicle registered?
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  • Relationship to Proposer?
  • Insurance Company
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  • Policy Number
  • Driving Frequency
  • How many years No Claims Discount/Bonus
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Details of Claims In The Past 6 Years (If Any)

  • Claim 1

  • Date
  • Type
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  • Amount (€)
  •  
  •  
  • Claim 2

  • Date
  • Type
  •  
  • Amount (€)
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  • Claim 3

  • Date
  • Type
  •  
  • Amount (€)
  •  
  •  
  • Claim 4

  • Date
  • Type
  •  
  • Amount (€)
  •  
  •  

Other Details

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  • House Insurance Renewal Date?

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  • Which Credit Union Are You Associated With*
  • Where Did You Hear About CUsafe?*

  • I confirm that the following Assumptions are correct: