RAPID REBATES Client Data Client Data Personal InformationSummary Personal Information Agent Initial Title MRMRSMISSMSDRPROFREV First Name * Last Name * Email Address * Phone Number Primary Address * Address Street Address Street Address Street Address 2 Street Address 2 City City State/Province State/Province Post Code Post Code Address Date Of Birth D1 * D2 M1 M2 Y1 Y2 Y3 Y4 Employment Details 1 A Employment Year 2019 -20202020 – 20212021 – 20222022 – 2023 Employer Name 1 A Work From Home 1 A Yes No Industry 1 A Agriculture Airlines Aluminium Armed forces Banks and building societies Brass and copper Building Building materials Clothing Constructional engineering (includes buildings, shipyards, bridges and roads) Electrical and electricity supply Fire service Food Forestry Glass Heating Iron and steel Iron mining Leather Other Particular engineering (work on commercial basis in a factory or workshop producing components such as wire, springs, nails and locks) Police force Precious metals Printing Prisons Public service ? docks and inland waterways Public service ? public transport Quarrying Railways Seamen Shipyards Textiles and textile printing Trades ancillary to engineering Vehicles Wood and furniture Job 1 A Car/Van Mileage Details 1 A Motorcycles 1 A Bicycle 1 A Car Employers Contribution 1 A 5p per mile10p per mile115p per mile20p per mile25p per mile30p per mile35p per mile40p per mile Motorcycle Employers Contribution 1 A 5p per mile10p per mile115p per mile20p per mile Bicycle Employers Contribution 1 A 5p per mile10p per mile115p per mile Car 1 A 5.1 Motorcycle 1 A 5.7 Cycle 1 A 5.9 Car 1 A 5.2 Motorcycle 1 A 5.8 Cycle 1 A 5.10 Car 1 A 5.12 Motorcycle 1 A 5.12 Cycle 1 A 5.12 Car 1 A 5.3 Car 1 A 5.4 Car 1 A 5.5 Car 1 A 5.6 Mileage Allowance 1 A 5.11 Mileage Allowance 1 A 5.12 Mileage Allowance 1 A 5.13 Other Expense 1 A 7.1 Other Expense 1 A 7.2 Other Expense 1 A 7.3 Other Expense 1 A 7.4 Total Expense 1 A 9.1 Employment Details 1 B Employment Year 2019 -20202020 – 20212021 – 20222022 – 2023 Employment Year 1 B Employer Name 1 B Work From Home 1 B Yes No Industry 1 B Agriculture Airlines Aluminium Armed forces Banks and building societies Brass and copper Building Building materials Clothing Constructional engineering (includes buildings, shipyards, bridges and roads) Electrical and electricity supply Fire service Food Forestry Glass Heating Iron and steel Iron mining Leather Other Particular engineering (work on commercial basis in a factory or workshop producing components such as wire, springs, nails and locks) Police force Precious metals Printing Prisons Public service ? docks and inland waterways Public service ? public transport Quarrying Railways Seamen Shipyards Textiles and textile printing Trades ancillary to engineering Vehicles Wood and furniture Job 1 B Claim Value 1 B 3.1 0 Car/Van Mileage Details 1 B Motorcycles 1 B Bicycle 1 B Car Employers Contribution 1 B 5p per mile10p per mile115p per mile20p per mile25p per mile30p per mile35p per mile40p per mile Motorcycle Employers Contribution 1 B 5p per mile10p per mile115p per mile20p per mile Bicycle Employers Contribution 1 B 5p per mile10p per mile115p per mile Car 1 B 5.1 Motorcycle 1 B 5.7 Cycle 1 B 5.9 Car 1 B 5.2 Motorcycle 1 B 5.8 Cycle 1 B 5.10 Car 1 B 5.12 Motorcycle 1 B 5.12 Cycle 1 B 5.12 Car 1 B 5.3 Car 1 B 5.4 Car 1 B 5.5 Car 1 B 5.6 Mileage Allowance 1 B 5.11 Mileage Allowance 1 B 5.12 Mileage Allowance 1 B 5.13 Other Expense 1 B 7.1 Other Expense 1 B 7.2 Other Expense 1 B 7.3 Other Expense 1 B 7.4 Total Expense 1 B 9.1 Employment Details 1 C Employment Year 2019 -20202020 – 20212021 – 20222022 – 2023 Employment Year 1 C Employer Name 1 C Work From Home 1 C Yes No Industry 1 C Agriculture Airlines Aluminium Armed forces Banks and building societies Brass and copper Building Building materials Clothing Constructional engineering (includes buildings, shipyards, bridges and roads) Electrical and electricity supply Fire service Food Forestry Glass Heating Iron and steel Iron mining Leather Other Particular engineering (work on commercial basis in a factory or workshop producing components such as wire, springs, nails and locks) Police force Precious metals Printing Prisons Public service ? docks and inland waterways Public service ? public transport Quarrying Railways Seamen Shipyards Textiles and textile printing Trades ancillary to engineering Vehicles Wood and furniture Job 1 C Claim Value 1 C 3.1 0 Car/Van Mileage Details 1 C Motorcycles 1 C Bicycle 1 C Car Employers Contribution 1 C 5p per mile10p per mile115p per mile20p per mile25p per mile30p per mile35p per mile40p per mile Motorcycle Employers Contribution 1 C 5p per mile10p per mile115p per mile20p per mile Bicycle Employers Contribution 1 C 5p per mile10p per mile115p per mile Car 1 C 5.1 Motorcycle 1 C 5.7 Cycle 1 C 5.9 Car 1 C 5.2 Motorcycle 1 C 5.8 Cycle 1 C 5.10 Car 1 C 5.12 Motorcycle 1 C 5.12 Cycle 1 C 5.12 Car 1 C 5.3 Car 1 C 5.4 Car 1 C 5.5 Car 1 C 5.6 Mileage Allowance 1 C 5.11 Mileage Allowance 1 C 5.12 Mileage Allowance 1 C 5.13 Other Expense 1 C 7.1 Other Expense 1 C 7.2 Other Expense 1 C 7.3 Other Expense 1 C 7.4 Total Expense 1 C 9.1 Employment Details 1 D Employment Year 2019 -20202020 – 20212021 – 20222022 – 2023 Employment Year 1 D Employer Name 1 D Work From Home 1 D Yes No Industry 1 D Agriculture Airlines Aluminium Armed forces Banks and building societies Brass and copper Building Building materials Clothing Constructional engineering (includes buildings, shipyards, bridges and roads) Electrical and electricity supply Fire service Food Forestry Glass Heating Iron and steel Iron mining Leather Other Particular engineering (work on commercial basis in a factory or workshop producing components such as wire, springs, nails and locks) Police force Precious metals Printing Prisons Public service ? docks and inland waterways Public service ? public transport Quarrying Railways Seamen Shipyards Textiles and textile printing Trades ancillary to engineering Vehicles Wood and furniture Job 1 D Claim Value 1 D 3.1 0 Car/Van Mileage Details 1 D Motorcycles 1 D Bicycle 1 D Car Employers Contribution 1 D 5p per mile10p per mile115p per mile20p per mile25p per mile30p per mile35p per mile40p per mile Motorcycle Employers Contribution 1 D 5p per mile10p per mile115p per mile20p per mile Bicycle Employers Contribution 1 D 5p per mile10p per mile115p per mile Car 1 D 5.1 Motorcycle 1 D 5.7 Cycle 1 D 5.9 Car 1 D 5.2 Motorcycle 1 D 5.8 Cycle 1 D 5.10 Car 1 D 5.12 Motorcycle 1 D 5.12 Cycle 1 D 5.12 Car 1 D 5.3 Car 1 D 5.4 Car 1 D 5.5 Car 1 D 5.6 Mileage Allowance 1 D 5.11 Mileage Allowance 1 D 5.12 Mileage Allowance 1 D 5.13 Other Expense 1 D 7.1 Other Expense 1 D 7.2 Other Expense 1 D 7.3 Other Expense 1 D 7.4 Total Expense 1 D 9.1 Authorise Nominee Name Nominee Address 1 Nominee Address 2 If you are human, leave this field blank. Next