To apply for the Extended Insurance Plan please read and complete Section A below and
Section B overleaf.
(Please complete in black ink using BLOCK CAPITALS)
Section A - Your Details
Title
Initials
Surname
Telephone
Email Address
House Number
Address
Postcode
Important Data Protection Information
Domestic & General Services Limited and Domestic & General Insurance PLC are members of the
Domestic & General Group.We (or our agents) and Vax Limited will use your personal details and
information we obtain from other sources for customer services and administration, for marketing
and to analyse your purchasing preferences. We may keep your information for a reasonable period
for these purposes.
We or our business partners may contact you by mail, telephone, e-mail or other electronic
messaging services with offers of goods and services or information that may be of interest to you.
By providing us with your telephone number or email address you consent to being contacted by
these methods. If you do not wish to receive marketing information by these methods from
Vax Limited and Domestic & General tick this box
or our other business partners
tick this box
.
Product Details
Date of Purchase
Purchase Price £
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SCHEME
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Section B overleaf
in addition please
complete Section B
Insurance Details and
Payment Method
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