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* Type of Policy : New  Renewal 
* City of Registration :
* Year of manufacture :  
* Manufacturer :
* Model :
Transfer "No-claim bonus" from
previous car : 		Yes  No 
Voluntary excess :
Additional Covers :
Value of electrical accessories :
Value of non-electrical
accessories :
Value of LPG/CNG kit, if
externally fitted :
Sum insured for passengers
under personal accident :
Insure paid driver? Yes  No 
Discounts :
Do you have an ARAI approved
anti-theft device in your car?		 Yes  No 
Are you a member of the Automible Association? Yes  No 
Date of Birth (Registerd Owner):    
(proof required)
Profession (Registerd Owner):
(proof required)
Personal Details
* Proposer Name :
* E-mail :
* City :   
Contact No. :  
* Mobile :