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Please fill out the form below and we will send you an itemized quote for your insurance provider.
Date
*
MM slash DD slash YYYY
Name of Policy Holder
*
First
Last
Name of Intended User
*
First
Last
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
*
Email
*
Quantity
Items to be Quoted
*
TravelScoot Original Mobility Scooter
TravelScoot Aviator Mobility Scooter
TravelScoot Elite Mobility Scooter
Add Accessories
Foldable Shopping Basket
TravelScoot Throttle Assist
TravelScoot Travel Set
4 Piece Cruise Kit
Foldable Shopping Basket
Price:
Suspension Seat Post
Price:
TravelScoot Throttle Assist
Price:
Beverage Holder & Mug Set
Price:
TravelScoot Travel Set
Price:
4 Piece Cruise Kit
Price:
GST
Price:
$ 0.00 CAD
PST
Price:
$ 0.00 CAD
Total
$ 0.00 CAD
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