Level of cover required  Latest Rates

Roadside, Recovery to local garage £29.50 Roadside, Recovery to local garage plus Home Call Out £42.50 Roadside , Recovery plus Home Call Out £47.50 Max 50 Mile Distance Recovery

e-mail:

Mr Mrs Ms Miss Dr Rev Initials Surname

Full Address

Post Code:

Vehicle Make:

Model:   Type:

Registration No.    Year:

Preferred Start Date

If you have more than one vehicle please enter details of second vehicle in info box below.

Info Box for second vehicle: Make - Model - Year - Reg No.

DECLARATION I declare that:

a/  The above information is correct.

b/ The above vehicle is 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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After we have received your application and provided the application form is fully completed you will receive:

• The 24 hour Emergency Service number

•  A Certificate of Membership 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

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

SAFE MOTORING