Motor Application Form "*" indicates required fields Step 1 of 8 12% Quote ReferenceImportant DocumentsHalligan’s Terms and ConditionsThis field is hidden when viewing the formDocuments End SectionSimply complete the Motor Online Form in full and your personal quote will be emailed promptly. Open 9am to 5pm, Mon to Fri.Proposer DetailsTitle*Mr.Ms.Mrs.Miss.Name* First Last Date of Birth* Day Month Year Gender* Male Female Employer and Union*AGSIAn Post CUCWU MemberFirst Tech CUGSRMAIPUISMEStaff Number*Employment Status*EmployedHousehold DutiesRetiredSelf EmployedUnemployedOccupation*Employers Business*Mobile Number*Email Address* Home Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Are you a Homeowner?* Yes No What is your home insurance renewal date? Day Month Year Please confirm if you are a Republic of Ireland permanent resident?* Yes No Since when have you been a Republic of Ireland Resident?* Day Month Year Do you have a second car at home?* Yes No 2nd Car Details Registration Number Current Insurer No Claims Discount Actions Edit Delete There are no Vehicles. Add Vehicle Maximum number of vehicles reached. Proposer's Driving Licence DetailsDriving Licence Type*Full IrishProvisional LicenceFull EU LicenceFull UK LicenceInternational LicenceDriving Licence NumberLicence Date Day Month Year Licence Restrictions*No RestrictionsAutomatic TransmissionOne Year LicenceTwo Year LicenceThree Year LicenceFour Year LicenceFive Year LicenceSuitably Adapted for DisabilityNumber of Years Previously Insured*Please enter a number greater than or equal to 0.Do you have any Driving Qualifications* Yes No List of Qualifications Qualification Type Date Earned Reference Number Actions Edit Delete There are no Qualifications. Add Qualification Maximum number of qualifications reached. Required QuestionsPlease answer all of the below questionsHave you previously been refused cover or had it cancelled?* Yes No Do you have any Non-Motor convictions?* Yes No Do you currently have any motor prosecutions pending?* Yes No Have you been previously Imposed Terms?* Yes No Do you have any penality points?* Yes No Total Number of Penalty Points*Please enter a number from 0 to 10.Penalty Point Details Offence Number of Points Date Applied to Licence Actions Edit Delete There are no Penality Points. Add Penality Point Maximum number of penality points reached. Do you have any convictions/disqualifications?* Yes No Convictions/Disqualifications Details Date of Conviction Conviction Type Amount Fined Months Disqualified Was conviction a result of an accident? Actions Edit Delete There are no convictions. Add conviction Maximum number of convictions reached. Have you had any Claims/Accidents?* Yes No List of Claims/Acidents Claim Date Type of Claim Is the Claim Settled? Total Claim Value? Actions Edit Delete There are no Claims. Add Claim Maximum number of claims reached. Do you have a medical condition?* Yes No List of Medical Conditions When did you first get Diagnosed? Select Medical Condition from List? Actions Edit Delete There are no Medical Conditions. Add Medical Condition Maximum number of medical conditions reached. Vehicle DetailsCar Registration*Make sure to double-check the reg is correct.Exact Make & ModelCCVehicle Year*Number of seats in car*Current Value*Fuel Type*DieselPetrolHybridFully ElectricTransmission*ManualAutomaticCar Body Type*ConvertibleCoupeEstateHatchbackSaloonSecurity Features*AlarmAlarm & ImmobiliserAlarm & TrackerAlarm, Immobiliser & TrackerImmobiliserImmobiliser & TrackerNoneIs the vehicle left hand drive?* Yes No When did you purchase your car?* DD slash MM slash YYYY Is the vehicle imported?* Yes No Do you have use of, or ownership of any other vehicle?* Yes No Does the vehicle have any modifications?* Yes No List all modifications made to vehicle Add RemovePlease add a new item for each modification. Click on the + symbol on the right to add a new entry.Relationship to Policy Holder*BrotherBrother in LawCommon Law SpouseDaughterDaughter in LawFather in LawMother in LawParentPartnerProposerRelativeSisterSister in LawSonSon in LawSpouseUnrelatedOvernight Parling*CarportGarageKept on Private RoadKept on Public RoadParked on DriveVehicle Registered in Republic of Ireland* Yes No Additional DriversDo you want to add any additional drivers?* Yes No List of Additional Drivers Name Date of Birth Gender Driving Licence Type Actions Edit Delete There are no Additional Drivers. Add Additional Driver Maximum number of additional drivers reached. Cover DetailsCover Start Date* Day Month Year Cover Type*ComprehensiveThird Party OnlyThird Party, Fire and TheftNo Claims Bonus Type*StepbackFullVoluntary Excess€0€250€300€500€600Specified Trailer Cover* Yes No Vehicle UseClass of Use*Social, Domestic and PleasureClass 1Main Area of UseCarlowCavanClareCorkDonegalDublinDublin 1Dublin 2Dublin 3Dublin 4Dublin 5Dublin 6Dublin 6WDublin 7Dublin 8Dublin 8Dublin 9Dublin 10Dublin 11Dublin 12Dublin 13Dublin 14Dublin 15Dublin 16Dublin 17Dublin 18Dublin 20Dublin 22Dublin 24GalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryWaterfordWestmeathWexfordWicklowEstimated MilesPersonal Miles*Business Miles (if any)Total MilesNo Claims BonusPrevious Insurer*Country Earned*Number of years Claim Free*01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9+ YearsDate you NCD will expire? Day Month Year This is normally your renewal date, unless there has been a gap in your cover. Data Protection AgreementWe comply with the provisions contained in the Data Protection Acts 1988 to 2018 we are committed to protecting and respecting your privacy. All calls, both inbound and outbound, may be recorded or monitored for quality, training and verification purposes. Data collected to bind your policy is passed by secure email in encrypted form within the meaning of the Act and GDPR, you have the right to request a copy of your details we hold on file and to change any inaccuracies or to cancel same unless we are legitimately obliged to retain same. If any doubt arises, contact info@halligan.ieAccept the Data Protection Statement* I confirm that I have read and accept the Data Protection Statement*Marketing Consent Please tick this box to allow us to contact you about discounts, special offers and information by post, email, SMS, phone and other electronic means.CommentsThis field is for validation purposes and should be left unchanged.
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