Insurance Policy Registration

If purchasing insurance either as a standalone policy or when you buy a manual wheelchair from us online, please complete this form to the best of your ability. If you’re unsure of any answers just leave blank and we can help you once we have received your order. If you’d like any further information, just get in touch!

PLEASE NOTE: This is for UK residents only

Insurance Policy Registration

CUSTOMER DETAILS
TITLE
NAME
First Last
DATE OF BIRTH
PHONE NUMBER
EMAIL ADDRESS - By taking out a policy online we will automatically send all correspondence via email. If you would prefer to receive your schedule and other correspondence by post, please tick the box below
- Please tick if you would prefer your documents sent by post
ADDRESS
Street Address Address Line 2 City County Postcode
AUTHORISED NAMED PERSON
ANY AUTHORISED NAMED PERSON? - If an Authorised Person will be acting on behalf of the Insured Person, please select 'Yes' and complete the Authorised Person's details below. If not just leave this section blank.
TITLE
NAME
First Last
PHONE NUMBER
DATE OF BIRTH
EMAIL ADDRESS - By taking out a policy online we will automatically send all correspondence via email. If you would prefer to receive your schedule and other correspondence by post, please tick the box below
- Please tick if you would prefer your documents sent by post
WOULD YOU LIKE TO USE THE INSURED PERSON OR THE AUTHORISED PERSON'S DETAILS FOR CORRESPONDENCE?
- Insured Person
- Authorised Person
EQUIPMENT DETAILS
EQUIPMENT TYPE
MANUFACTURER
IF YOU SELECTED 'Other' PLEASE TYPE THE MANUFACTURER HERE
MODEL
DATE OF MANUFACTURE
DATE OF PURCHASE
PURCHASE PRICE
STATUS
CLASS
SERIAL NUMBER

Insurance Policy Registration

Insurance Policy Registration

CUSTOMER DETAILS

AUTHORISED NAMED PERSON

EQUIPMENT DETAILS

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