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Application for the supply of SeniorSafety products

This service is for people who meet the following criteria:

  • Aged over 60
  • Savings under £20,000 (including shares, bonds, etc)

Please fill in the form below to apply.

Please note if you have previously referred a client via this form, in the Proposer section of this form you will only need to provide first name, surname and email.

Fields marked with * are required.

1.Proposer

 


2. Client



3. Accomodation




4. Gender


5. Age

6. Products









Data Protection Act 1998
Help the Aged is a registered charity (No. 272786). The data provided here will be used by Help the Aged for the purpose of administering the SeniorSafety Scheme.


 * I, the proposer, confirm that I have informed the client that I have collected personal details and passed them to Help the Aged for the purpose of administering the SeniorSafety Scheme.

 
 
 
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