Dolmen Insurance Brokers

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Name
Address
E-mail address
Risk Address (if different from above)
Occupation
Day time phone number
Fax
Date of Birth
Gender
Age of eldest person in the house
Buildings sum insured	€
Contents sum insured	€
Accidental Damage
Unspecified All risk Sum Insured (Cover away from the home)	€
Specified Items risks Sum Insured (Valuation Required)	€ € €
Is the house occupied during the day
How many years do you live at this address
What's the year that the house was built
Number of bedrooms
Smoke detectors
Working Alarm
NSAI Approved Alarm
Is alarm connected to a monitoring station
Name of installer
Neighbourhood Watch / Community Alert
Five Lever Locks on doors & windows
First time buyer ?
What is your current Car Insurer ?
Any Claims in the last 5 years ?
Details of any claims if applicable
Name of present insurer
Renewal Date
Cheapest quotation till so far	€

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	Dolmen Insurance Brokers Ltd
	Butterly Business Park Unit 44 Artane Dublin 5	Telephone:	01 867 2121
		LO-CALL:	1890 201 603
		Fax:	01 867 2123
		Email:	info@dolmen-insurance.ie
Dolmen Insurance Brokers Ltd is regulated by the Central Bank of Ireland Dolmen Insurance Brokers Limited is registered in Ireland as a private company limited by shares. Registration No. 293180. Registered office: 37/44 Butterly Business Park, Artane, Dublin 5, Ireland. Directors: D.P. Dillane (Managing Director), D.A. Dillane