Insure your Electronic Item
Laptop / PC
Title:
First name:
Middle Initial:
Surname:
Address:
Postcode:
-
Daytime Tel:
-
Email:
Product type:
Make & Model:
IMEI/Serial No.:
Level of cover:
Computercover 1 - £5 per month
(up to the value of £1000)
Computercover 2
- £7.50 per month
(up to the value of £1500)
Computercover 3
- £10 per month
(up to the value of £2500)
Dealers code/ Shop name:
How would you like to pay for your insurance?
Direct Debit (Monthly)
Credit Card (Annually)
DIRECT DEBIT DETAILS
Account holder name:
Bank/building society account number:
Bank/building society sort code:
-
-
CREDIT CARD DETAILS
Name on card:
Card Number:
Valid from:
\
Valid Until:
\
Issue Number:
I agree to all
terms and conditions
.
I have read the
key facts