Vintage Insurance Proposal Form
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I.V.E.T.A Vintage Insurance Proposal Form
Name:
Address:
Date of Birth:
Occupation:
Telephone Number:
Mobile Number:
Email Address:
IVETA Membership No:
Make & Model
Type of Vehicle
Year of
Reg / Chassis
Use of vehicle [please
e.g. car, tractor
Make
No.
circle]
Vintage Only/ Vintage &
Agricultural/ Vintage & SDP
Vintage Only/ Vintage &
Agricultural/ Vintage & SDP
Vintage Only/ Vintage &
Agricultural/ Vintage & SDP
Vintage Only/ Vintage &
Agricultural/ Vintage & SDP
1. Do you, or any person who will drive, suffers from any disability or
Yes / No
infirmity.
2. Have you, or any person who will drive, been involved in a motor accident in
Yes / No
the last 5 years.
3. Have you, or any person who will drive, had any convictions / penalty points
Yes / No
in the last 5 years.
If the answer to questions 1 – 3 above is yes, please provide details below:
Please confirm the insurance company with which you hold your main motor insurance policy.
Insurance Company:
Renewal Date: __________
Please confirm the insurance company with which you hold your home insurance policy.
Insurance Company:
Renewal Date: __________
If you wish to receive a quote on your main motor policy prior to renewal date,
Please tick here
Information on other products services and special offers can be obtained.
Signature:
Date:
Insurance Premium (Made Payable to Campion Insurance)
€
Membership Amount (Made Payable to IVETA)
€ 25.00
Please forward 2 separate cheques for the above amounts. Cover applicable to all vehicles is third
party only and driving is restricted to persons aged 25 to 70, with a full relevant Irish licence,
except for tractors where drivers must be 16 or over with a full / provisional Irish licence.
All quotations issued subject to our terms of business. Rates may vary mid year.
Our dedicated IVETA team are based in Portlaoise and are available on:
Main Contact Number: 057 8695700
Fax Number: 057 8622210
Email:
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