Loss Protection Plan Acceptance

Participant Name *

First

Last

Date of Birth *

Driver Licence Number *

Acceptance – Monthly Fee Applies (Loss limited to $250*) *

ACCEPT – I, the abovementioned participant, confirm that by submitting this form I acknowledge that I ACCEPT the optional Loss Protection Plan. Upon regular payment of the Loss Protection Plan fee, the Participant’s financial responsibility for loss of the System shall be limited to a maximum of $250.00 per occurrence provided the Terms and Conditions in the User Manual area met.
DECLINE – I, the abovementioned participant, confirm that by submitting this form I acknowledge that I DECLINED the optional Loss Protection Plan. I understand that I will be responsible for any loss or damage to the system with a complete loss valued at $900 (non camera) or $1300 (camera system)

*T&C apply

Declaration Date *