Home Third Party Online Insurance Premium

IDV	`
Policy Start Date
Premium	`
CGST (18.00% of Premium)	` 0.00
SGST (18.00% of Premium)	` 0.00
IGST (18.00% of Premium)	` 0.00
UGST (18.00% of Premium)	` 0.00
(for Package Premium)	` 0.00

Date:

Make & Model :

A. Liability

Basic Liability Premium:

`

Liability for Bi-Fuel Kit:

` 0.00

Sub Total (A):

` 0.00

C. Add-On Covers

Total Cover:

B. Additional Covers

PA For Unnamed Passenger:

` 0.00

Compulsary PA Cover For Owner Driver:

` 0.00

Legal Liability To Paid Driver:

` 0.00

Sub Total (B):

` 0.00

Total Liability Premium (C = A + B):

` 0.00

Total Premium:

` 0.00

Personal Details

Gender:

Male Female

Communication Address

Registration Address

Is the Car registered at the same address as above?

YES NO

Inspection Address

e.g.(MH 12 AB 3168)

PA Cover for Owner Driver

Is the nominee / guardian address same as the communication address?

YES No

Is your Car under Loan / Hypothecation / Lease ?

The car is under:

None Loan / Hypothecation Lease Hire / Purchase

Policy Details

IDV Adjustment:

Any claims made in Expiring policy ?

No Claim Bonus (NCB %) in Expiring Policy:

Voluntary Deductible ( in Rs. ):

Nil Depreciation:

PA Cover (10 Lacs):

Is Anti Theft Device Installed:

Member of Automobile Association:

Membership Number :

Personal Accident Cover (Rs 506/-):

Value of Electrical Accessories ( in Rs. ) :

Value of Non Electrical Accessories( in Rs. ) :

Policy Start Date :

Policy Expiry Date :

Manufacturing Month / Year :

Other Details

Nominee Name:

DOB of Nominee:

Relation with Owner:

Financier Name:

Financier Address:

Name of Previous Insurer:

Previous Policy No:

Insured Details

Name:

Gender:

Date of Birth:

Email ID:

Mobile Number:

Landline Number:

Communication Address

Flate Bulding Name:

Area Name:

State Name:

District Name:

City Name:

PinCode No.:

Vehicle Details

Engine No.:

Chassis No.:

Bike No.:

Purchase Date:

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Additional Details

Protect Yourself !!!

Date:

Make & Model :

A. Liability

B. Total Discount

C. Add-On Covers

B. Additional Covers

Personal Details

Communication Address

Registration Address

Inspection Address

PA Cover for Owner Driver

Is your Car under Loan / Hypothecation / Lease ?

Previous Insurance Details

Policy Details

Other Details

Insured Details

Communication Address

Vehicle Details

Payment Options

Select Payment Mode

Pay Using Credit Card

Pay using Net Banking

Pay Using Debit Card

Pay Using PayZippy

Immediate Payment Service (IMPS)

Pay Using Wallet

Pay Using UPI