Mobility Centre South West

Triple Star Cover Application Form

Triple Star Cover Application Form

How to use this application form:
Step 1: Please complete the ‘Statement of demands and needs’ section.
Step 2: Please ensure that all personal and product details are completed. Without this cover cannot commence.
Step 3: Please select your chosen type of cover.
Step 4: Please select method of payment. If paying by cheque please ensure
Step 5: Please ensure you read and understand the declaration, sign, date and return the form

    Step 1: Statement of demands and needs - Non Advised Sale

    If you answer yes to question 1 - please proceed with questions 2 and 3, as the following policies may be suitable.

    1. Do you own a mobility scooter/power-chair with a retail value of £6000 or less?

    2. Do you currently have insurance to cover your scooter/power-chair?

    3. Do you currently have an extended warranty to cover your scooter/power-chair?

    4. Have you ever held a policy with First Senior Insurance before?

    5. Have you read the insurance product information documents?

    Step 2: Personal and Product Details

    Title: First Name: Surname:
    Date of Birth:
    Address:

    Telephone:
    Date of Purchase:
    Make of Product:
    Model:
    Frame/Serial No:
    Year of Manufacture:
    Purchase Price:
    Class Type:

    Step 3: Types of Cover

    Please tick the boxes you would like cover for

    Triple Star Insurance

    Triple Star Roadside Recovery

    Triple Star Extended Warranty

    Sub-total

    Triple Star insurance total value
    Triple Star warranty total value
    Triple Star recovery total value
    Grand total

    Step 4: Method of payment

    We will contact you to process your card details or:
    I will send a cheque or:
    Pay by BACS to ***** Account Number 88888888 Sort code 90-90-90

    Step 5: Sign below

    1. I confirm that no personal recommendation has been provided to me and that these products meet my demands and needs

    2. I understand that I may return the certificate of insurance within 14 days for a full refund subject to no claims being made

    3. I have read and understand the 'Insurance Product Information Documents' within the brochure

    Declaration: I understand the contents of this completed application and I declare that the information given is to the best of my knowledge and belief correct and complete. I agree that the statements in this application shall form part of the contract between the insurer and myself and if the risk is accepted I undertake to pay the premium when called upon to do so. I understand that my information may also be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing the insurer's compliance with any regulatory rules/codes. First Senior Group may also from time to time send you details of services and other third-parties services that we think will be of interest to you. If you do not wish to receive this information, please tick here.

    Signed: (by typing your name in the box you are demonstrating an intent to sign and we acknowledge that this signature is attached to this document.
    Date: