Car / Van Insurance - Get a QuickQuote now!


     
   
 

 

  

 


Personal Details -
 

Contact Name:*

  
 

Address:

  
 
Date of Birth *
  
Day
Month
Year
 

Tel No: *

  
 

Mobile No: *

  
 

Email:

 
     

Have you ever been Insured with Pat Treacys before:

 

 

    

Occupation:

 
 

Licence Type:*

 
     
Current Insurance Renewal Date
 
Day
Month
Year
     
Best Renewal Price Quoted so far (optional)
  

 

    

Do you have your own Private Car Insurance Policy or/and are named on your spouses Private Car Insurance Policy, if so please give policy details:

 

 

    

Please declare any accidents/claims/convictions or penalty points:

 
     

Policy Cover required: Comp, Third Party etc.

 
     
 
    

No. of years no claims Bonus:

  


 

Vehicle Details -

   
 
    
     

Make/Model*

  
 
    

Engine Size: *

  
 
    
Carrying Capacity/Tonnage of Vehicle:
 
     

Value in Euro *

  
€
 
    
Is the Vehicle a crew cab?:
 
     
Year*
  
Year
     
State all purposes the vehicle will be used for, ie Goods Delivery, Haulage etc:
 
     

Is the Vehicle owned and registered in your name?:

 
     
Registered for VAT? :
 
     
Do you require Windscreen Cover / Personal Accident / Fatal Accident Cover?:
 
     
Additional Drivers:
 

 

If required, Please enter Additional Drivers Details Below

Name 1

Licence Type


Date of Birth

 

Accidents / Claims y/n
Name 2
 		Licence Type


Date of Birth



Accidents / Claims y/n

 

Name 3

Licence Type


Date of Birth

 

Accidents / Claims y/n

Please declare any further information regarding any other Insurance Policies you hold. This information will allows us to ensure that we are applying all relevant discounts to provide you with our most competitive Commercial Vehicle Insurance Quotation:

  
 
* = Required Information
 

 

 
 
 

 

Terms of Business

Car Insurance, Home Insurance, Life Insurance, Travel Insurance, Wedding Insurance, Commercial Insurance, Van Insurance, Life & Pensions