Customer Name

Customer Email

Phone Number

Aadhhar Number

PAN Number

Date of Birth

Vehicle Mode
—Please choose an option—PraviteCommercial

Vehicle Type
—Please choose an option—Two Willer BikeFour Willer CarFour Willer Good Carrier

Insurance Type
—Please choose an option—ComprahanciveThird PartyOD

Vehicle Number

Registration Date

Manifacture Date

Privious Insurance Expaired
—Please choose an option—YesNo

If Yes (Select)
—Please choose an option—3090180360

Privious Policy Name

Privious Policy Number

Any Claim
—Please choose an option—YesNo

Need Personal Cover
—Please choose an option—YesNo

Nominee Name

Nomini Aadhar

Date of Birth

Nominee Email

Nomini Phone

Relation

Agent ID

Agent Email

Agent Name