Level of cover required  Selection Commercial Vehicle Roadside Assistance £127.50

email:

Mr Mrs Ms Miss Dr Rev Initials Surname

Full Address

Post Code:

Vehicle Make:

Info Box for Multiple Vehicles: Make - Model - GVW - Year - Reg No.

If you have more than one vehicle please enter details of each vehicle in above info box

Excluded Vehicles

Ambulances, Motor Homes, Campers, Horse Boxes, Courier & Delivery and Furniture Removal vehicles

Model:   Type: GVW

Registration No.    Year:

Preferred Start Date

DECLARATION I declare that:

a/  The above information is correct.

b/ The above vehicle/s are in a roadworthy condition.

c/  No organisation providing similar cover has declined, refused to renew or cancelled my membership.

d/  I am not aware of any circumstances to give rise to a claim under this insurance

I understand that this proposal form is the basis of the contract between us. I agree to accept terms, conditions and exclusions contained in the Membership Certificate which will be issued to me upon acceptance of my application.

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When you press the Confirm Purchase button above a Thank You page will appear. The Thank You page means you have successfully registered your application and no further action is needed by you today.

After we have received your application and provided the application form is fully completed you will receive:

• The 24 hour Emergency Service numbers

•  A Certificate/s of Insurance detailing the level of service requested

•  A Postal Invoice

• Cover cannot commence until at least 48 hours have elapsed following the time of your application

•  Immediate cover cannot be offered

•  This application form is time stamped

Should any detail need verification or clarification we will correspond by e-mail. SAFE MOTORING