Account Services

Set up an Account for Wheelchair Accessible Taxi Service

Insurance Accounts

Personal Accounts

Business and Organisation Accounts

Charge Accounts

An easy way to set up monthly billing account. We can accommodate small to large size accounts for accessible transportation needs.

Personal Account

Personal Account Application

Name of the person opening the account *

Address *

Country

City

Phone *

Mobile Phone

Fax Number

Email *

Passenger's Details

Passenger's Name *

Passenger's Address *

Apt, suite, etc.

Country

City

Zip code

Passenger's Home Phone *

Passenger's Mobile Phone

Passenger's Email

Employer

Employer's Address

Employer's Phone Number

Current Position

Annual Salary

Years with current company

Financial Information

Bank / Trust Company

Bank Address

Account Number

Major Credit Card Number *

Expiry Date *

Billing Options

Email Invoice

Fax Invoice

Fax and Email Invoice

Billing Email

Billing Fax Number

PLEASE BE ADVISED THAT A DEPOSIT EQUAL TO THE VALUE OF ONE MONTHS WORTH OF TRIPS MAY BE REQUIRED

In applying for credit with Wheelchair Taxi Online., the undersigned consents to Wheelchair Taxi Online . obtaining from, exchanging with or disclosing to a third party all information concerning the Application for the purpose of ensuring the accuracy of this information and conducting investigations. The undersigned hereby authorizes Wheelchair Taxi Online. through an affiliated company to collect Any overdue balance on my account by charging one of the above credit cards

Signature

Reset Signature

Date

Insurance Account

Insurance Account Application

Insurance Company Name *

Bill To

Insurance Company's Billing Address *

Apt, suite, etc.

Country

City

State

Zip code

Billing Fax Number

Billing Email

Billing Contact Person or Adjuster *

Adjuster's Mobile Phone

Adjuster's Phone Number

Billing Contact Email Address

Billing Options *

Email Invoice

Fax Invoice

Fax and Email Invoice

Please fill out only if someone other then the adjuster listed above is filling out this form

PERSON SETTING UP ACCOUNT

COMPANY

ADDRESS:

Phone

Passenger's Details

Claim Number *

Passenger's Name *

Passenger's Home Phone *

Passenger's Mobile Phone

Passenger's Email

Passenger's Address *

Apt, suite, etc.

Country

City

Zip code

Account Ristrictions

Who will be booking the Trips?

Client

Insurance Company

Rehab or Physio Team

Case Manager or Lawyer

Are There Any Restrictions to Travel

Yes

IF RESTRICTED TO SPECIFIC ADDRESSES, PLEASE LIST:

Instructions

The undersigned acknowledges that they have the authority to open this account on behalf of the previously named insurance company

PRINT FULL NAME OF INSURANCE ADJUSTER *

SIGNATURE OF INSURANCE ADJUSTER

Reset Signature

Date

Account for Organisation

\contact us to set up an account for Organisation.

647 696 8555

info@wheelchairtaxi.online

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