Insurance Form

Insurance Form

Date of Insurance:

Customer Name:

Customer Contact:

Type:

Make:

Model:

Fuel Type:

Variant:

Year of Mfg: Enter a valid 4-digit year

Registration No:

ID Value (₹):

OD Value (₹):

Final Premium (₹):

NCB (%):

Insured Company:

Insurer Code:

Policy No.:

Term COMP:

Term TP:

24x7 Roadside Assistance Accidental Cover Consumables Daily Allowance cover Deductible Electrical Accessories Engine Protection Cover Invoice Price Cover Key & Lock Replacement Loss of Personal Belongings cover No Claim Bonus Protection Non-Electrical Accessories Passenger cover Tyre Protector Zero Depreciation Others

No Add-Ons Selected

CKYC No.:

Reference 1:

Reference 1 Contact:

Reference 2:

Reference 2 Contact:

Transfer to:

Upload Insurance File

Upload RC Front

Upload RC Back

Upload Aadhaar Card Front

Upload Aadhaar Card Back

Upload PAN Card