Duplicate Certificate or Disc

Duplicate Certificate and/or Disc required
1. Your Details:
Relationship	Direct Customer Broker
Policy Number
Name
Registration Number
Contact Phone Numbers	Home
	Work
	Mobile
Email Address

I require:	Duplicate Certificate Disc Both
2. Declaration: Please read this Lost Certificate /Disc Declaration and you must complete the box below. In pursuance of Article 7 of the Road Traffic Regulations 1962, I , being the person to whom the Certificate of Insurance described below was issued hereby apply to RSA for a new Certificate and/or Disc of Insurance and I declare that the said Certificate and/or Disc has been lost /destroyed under the following circumstances:

Note: Please note that cover cannot be backdated. In the event that you require immediate confirmation of cover, please contact the Motor Team on (01) 6363524.

RSA is a registered business name of RSA Insurance Ireland Limited. RSA Insurance Ireland Limited is regulated by the Central Bank of Ireland and is a private company limited by shares registered in Ireland under number 148094 with registered office at RSA House, Dundrum Town Centre, Sandyford Road, Dundrum, Dublin 16. The Directors are Simon Lee (British), Philip Smith, Fergus Clancy, Roy Keenan, Orlagh Hunt, Jack McIlduff, Iain Walsh, Paul Kierans, Rory O’Connor and Leo Blennerhassett.