Motor Insurance - Kelleher Insurances

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Full Name*

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Date of Birth*

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Do you or any named driver have a medical condition which needs to be notified to the Licencing Authority?*

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Licence Details

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What is the country of issue*

Have you or any named driver have penalty points*

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Do you or any of the named drivers have any convictions*

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Ban length*

Fine*

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Have you or any named drivers made any claims in the last 5 years*

How many*

Name

First Last

Type of accident*

At Fault*

Yes
No

Cost of claim*

Outcome*

Year*

Description of claim

Name

First Last

Year - 1st Claim*

Type of accident - 1st Claim*

At Fault - 1st Claim*

Yes
No

Cost of claim - 1st Claim*

Outcome - 1st Claim*

Description of claim

Name

First Last

Year - 2nd Claim*

Type of accident - 2nd Claim*

At Fault - 2nd Claim*

Yes
No

Cost of claim - 2nd Claim*

Outcome - 2nd Claim*

Description of claim

Name

First Last

Year - 3rd Claim*

Type of accident - 3rd Claim*

At Fault - 3rd Claim*

Yes
No

Cost of claim - 3rd Claim*

Outcome - 3rd Claim*

Description of claim

Name

First Last

Year - 4th Claim*

Type of accident - 4th Claim*

At Fault - 4th Claim*

Yes
No

Cost of claim - 4th Claim*

Outcome - 4th Claim*

Description of claim

Name

First Last

Year - 5th Claim*

Type of accident - 5th Claim*

At Fault - 5th Claim*

Yes
No

Cost of claim - 5th Claim*

Outcome - 5th Claim*

Description of claim

Vehicle details

Make*

Model*

Engine Size*

Fuel type

If other please describe fuel type*

Registration no*

Body style*

No. of seats

Value*

Are there any modifications to your vehicle?*

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Cover Details

Cover type*

Current renewal date*

Current no claims bonus*

Current insurer*

Who are you insuring*

Named driver details

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Date of birth*

Sex*

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Occupation*

Named Driver Licence Details

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What is the country of issue*

Relationship*

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