GET A LIABILITY QUOTE

Name (Proposer)

First Name Last Name
Company Name
Correspondence Address

Street Address

Street Address Line 2

City County

Eircode
Is the Correspondence Address the same as the Risk Address

Yes No
Risk Address

Street Address

Street Address Line 2

City County

Eircode
Contact Name
Email
example@example.com
Phone Number

Area Code Phone Number
Mobile Number

Area Code Phone Number
Please provide a full business description of the services you provide
Are You Full or Part-Time

Full Time Part Time

Projected Wages & Turnover for the coming 12 months:

	Number	€
Clerical
Direct Employees
Labour Only sub-contractors
Bona fide sub-contractors
Turnover

Turnover for the past 12 months
Any previous claims in the last 5 years?

Yes No
Please supply full details of any claims in the last 5 years
Do you currently hold liability insurance

Yes No
Present Insurer
Renewal Date
Any other relevant information
Should be Empty: