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Copy
of the Insurance Declaration,
which
all members are required to read and sign.
To : The Ecclesiastical Insurance Group
I confirm that as far as I am aware I do not have
any physical or mental condition which would impair my ability to operate the
equipment which is to be lent/hired to me by Shopmobility York and that I
have not been advised by my General Practitioner or usual qualified assessor of
any physical or medical condition which could affect my ability to operate the
said equipment.
NOTE:
If a satisfactory declaration cannot be provided,
then prior to insurance cover being provided, it will be necessary for a note
from your doctor or qualified assessor to be provided confirming that in his/her
opinion you are fit to operate the equipment in question.
If you have been advised by your doctor or
qualified assessor of a physical or medical condition which would render you
unfit to operate the equipment in question, then we regret insurance cover
cannot be provided.
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