Home Insurance - Kelleher Insurances

Data Consent*
- I confirm that I give my Data Processing Consent to Kelleher Insurances to process all Data.
Full Name*
Address
Street Address
Address - Line two
Street Address Two
Address - Town/City
Town/City
Address - County
County
Address - Eircode
Eircode
Email Address*
Phone No*
For Marketing Preferences – Please advise to agreed methods of Contact:*
- Email
- Phone
- SMS
- Please do NOT contact me
Date of Birth*
Occupation
The property that I am insuring*
Address
Street Address
Address - Line two
Street Address Two
Address - Town/City
Town/City
Address - County
County
Address - Eircode
Eircode
Address - Eircode
Eircode
County of the Property*
I require buildings sums insured of*
With accidental damage*
- Yes
- No
I require contents sum insured of*
All risks required*
Unspecified sum insured*
Specified sum insured*
- Yes
- No
Total specified sum insured*
Existing Insurer
Current Renewal Date
Any Claims in last 5 years*
Number of claims*
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
2nd Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
3rd Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
4th Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
5th Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
6th Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
7th Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
8th Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
9th Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
10th Claim
Year of last claim*
Cause of claim*
Please Specify*
Amount claimed*
Staus*
Any additional information

2nd Claim

3rd Claim

4th Claim

5th Claim

6th Claim

7th Claim

8th Claim

9th Claim

10th Claim