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  Mobility Scooter and Powered Wheel Chair Breakdown Application Form


Assistance powered through leading Mobility Vehicle Recovery Groups. Apply Today


Register Now - Completion of this form will lead you PayPay/Credit/Debit Card payment options

Reliable Professional Assistance is quickly available/unbeatable service/unbeatable price.

Present average attendance time is 30-40 minutes.


We shall not impose any options or penalties to members as we believe you should be treated to only the best service at the very lowest membership fee ever. You can join over the phone on 01604 757578

Insert Level of Cover Required, Name, Email, Address, Post Code and Vehicle Details. Let's Go!  - All questions mandatory

Level of cover required:




Contact Numbers - Please advise at least one

Tel: Home: Mobile: Work:


Initials: Surname:


Full Address


Post Code:


Mobility Vehicle Make:


Model:   Type:


Serial Number .    Year:



Preferred Start Date


Your 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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When you press the Confirm Purchase button above you will be taken to a payment page to complete your purchase.


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

  • The 24 hour Emergency Service number

  •  Membership documentation detailing the level of service requested

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




Thank You
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