One Month Free Insurance

Title: Mr Mrs Master Miss Ms

First Name:

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To do our bit to save the planet, this is an online only policy. Provide your e-mail address so we can email you your policy documents and you can manage everything through our customer portal.

If you really need your policy documents posting to you please tick below:

Please post my policy documents

Make:

Model:

Serial Number:

Purchase Price:

Date of Manufacture:

Delivery Date:

Classification:

Condition:

I understand the contents of this application form and the cover provided. I confirm that I am in receipt of an Insurance Product Information Document and wish to proceed.

I have not had an incident involving mobility equipment within the last 3 years which would have resulted in a claim for the insurance described in the Insurance Product Information Document.

I agree that any information provided to Mark Bates Ltd regarding me for the purposes of accepting insurance and I agree that any information provided to Mark Bates Ltd regarding me for the purposes of accepting insurance and handling any claims may, if necessary, be divulged to third parties, provided it will be processed in compliance with the provisions of the General Data Protection Regulation and Privacy Policy which is available on request.

If you cannot confirm any parts of this declaration please call us on 01476 512190. Non disclosure may invalidate your insurance.

Please note your free cover will not commence until the completed application is received at Mark Bates Ltd, Premier House, Londonthorpe Road, Grantham, NG31 9SN. If you have not received your policy documentation within 10 days of competing this form, please call 01476 591104.