Section I. Applicant Information

Questions 1 to 8 of the Mobility Scooter / Medical Equipment supplemental application. Fields marked * are required.

Proposed Effective Date

Named Insured(s)

Mailing Address

City

County

State

Zip Code

Primary phone

Cell / Home / Work

CellHomeWork

Secondary phone (optional)

Cell / Home / Work

CellHomeWork

Primary email

Secondary email (optional)

Date of Birth

Occupation / Employer

Good to know: when you press Save and continue, we save your answers and email a private link to the email address you entered above, so you can come back and finish on any device within 30 days. You will get this email even if you finish today; there is nothing you need to do with it.

Your answers are saved every time you move to another section. Need a break? Press Save and finish later and we will email you a private link (kept for 30 days).

Questions? Call 800-616-3490 or email quote@societiesinsurance.com.