Read and complete Section A and Section B and return this form in an envelope to:
Vax Guarantee Department, c/o Domestic & General Insurance PLC, Leicester House,
17 Leicester Street, Bedworth,Warwickshire, CV12 8JP.
Section B - Insurance Details and Payment Method
Insurance Details
Period of protection required -
additional 2 years
additional 4 years
Fee £
Payment Method
I wish to pay by direct debit over 10 months (please complete mandate below)
I enclose a Cheque/Postal Order payable to Domestic & General Insurance PLC
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Declaration
I confirm that I have read Sections A and B and I hereby apply for the Vax Insurance Plan in accordance with the
terms and conditions of your plan. I confirm that the equipment is in good working order and used for domestic purposes only
and declare that the details in this proposal are true and complete to the best of my knowledge and belief.
Signature
Insurance Purchase Date
Warning: Any false statement may render your plan invalid
DIRECT DEBIT PAYMENT PLAN
Instructions to your Bank or Building Society to pay by Direct Debit
Reference Number
- for office use only
Originators ID. No.
Instruction to your Bank or Building Society
Please pay Domestic & General Insurance PLC Direct Debits from the account detailed in this instruction subject to the
safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with Domestic & General
Insurance PLC and, if so, details will be passed electronically to my Bank/Building Society.
To The Manager
Bank Building Society
Address
Postcode
Name(s) of Account Holder(s)
Bank/Building Society Sort Code
Account Number
DOMESTIC & GENERAL INSURANCE PLC OFFICIAL USE ONLY
This is not part of the instruction to your Bank or Building Society
If you have a preferred collection date from your account (1st to the 28th only) please complete this section
Signature
Date
Banks and Building Societies may not accept Direct Debit Instructions for some types of account
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