PDF version - Autonational Rescue

Join Autonational Rescue today: complete
this form or call us by ringing local call
08459 100 345
Thanks for printing the online application form, simply complete it and scan it attaching it to an email to [email protected].
Or post it to us, free of charge, to: Autonational Rescue, PO Box 3928, Swindon, SN4 4GQ.
Name: Date of birth:
Address: Email:
Postcode:
Tel. No. (Home):
Where did you hear about us?
Tel. No. (Work):
Important: Cover is available in the UK only on private cars, car derived vans and motorcycles over 150cc. Unfortunately, to keep
our prices competitive, we cannot cover LCVs, pick-ups, caravanettes, minibuses or left-hand drive American cars. Nor can we cover
vehicles used as taxis for private or public hire.
Details of vehicle(s) 1st Vehicle
2nd Vehicle
Make
Model
Registration number
Date 1st registered
Important: You qualify for the 25% no claims bonus provided you have not had a breakdown in the last 12 months. Simply tick the
appropriate box when you select your service or services below.
With
25% Bonus
All inclusive package
Total Superservice
£69.00
Or choose your level of cover (tick as required)
Without
25% Bonus
£92.00
With
25% Bonus
With
25% Bonus
Without
25% Bonus
£34.50
Without
25% Bonus
£46.00
With
25% Bonus
Without
25% Bonus
Roadside SuperService (must be taken)
£27.00
£36.00
£13.50
£18.00
Recovery SuperService
£30.00
£40.00
£15.00
£20.00
Home SuperService
£21.00
£28.00
£10.50
£14.00
Alternative Travel/Accommodation
£15.00
£20.00
£7.50
£10.00
Caravan SuperService
£9.00
£12.00
£9.00
£12.00
DECLARATION
I confirm that the vehicle(s) to be covered is/are in good working
order and in normal use and kept at the address above. I confirm
that I accept and agree to abide by the terms of the insurance and
that the vehicle(s) will not be used for private or public hire, racing,
rally or competition purposes. If I am claiming the 25% bonus
discount, I also confirm that during the 12 months immediately
preceding this application, I have not driven a vehicle that has
suffered a breakdown.
Signature
Date
I enclose my remittance for
the total amount due of:
Please make cheques payable to Autonational Rescue and write
your vehicle(s) registration details on the reverse.
£
Or, I authorise you to debit my credit/debit card:
Cardholder’s name:
Cardholder’s address:
Card number:
Valid from date:
Expiry date:
/
/
Issue number (Maestro card only):
Security code:
Cover commences from midnight on the day we receive your application, unless you specify a later date here:
/
/
Administered by ERS Syndicate Services Limited. ERS Syndicate Services Limited (company no. 02661753) is an Appointed Representative
(firm reference no. 402561) of ERS Syndicate Management Limited and provides administrative services for ERS Syndicate Management Limited
which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation
Authority (firm reference no. 204851). ERS Syndicate Services Limited is registered in England and Wales with its registered office at Library
House, New Road, Brentwood, Essex CM14 4GD.
AUT JF 10_14