General Information

Product *

Product Type *

Policy Type *

Is Manufacturer Warrenty Valid *

Tenor *

Reference Number *

Creation Date

Location *

User *

Group *

Issued By *

Sales Consultant *

Customer Type *

Currency *

Sale Method *

Policy Effective Date *

Policy Expiry Date *

Customer Information

Title *

First Name *

Middle Name *

Last Name *

Full Name

Gender

Male

Female

Email ID

Company Name

ID Type *

ID Number*

ID Expiry*

Date of Birth*

Mobile Number*

Alt Mobile Number*

P O Box*

Emirates*

Nationality*

Address*

Vehicle Info

Vehicle Sales Type *

Vehicle Make *

Vehicle Model *

Variant *

CC *

Cylinder *

Invoice/Sold Date *

Vehicle Invoice Value *

Body Type *

Color *

Model Year *

Chassis Number *

Engine Number *

Kilometres *

Manufacturer Warranty Expiry Date *

Manufacturer Warranty Cover *

Unit Details

Sales Price *

Serial No *

Chassis Number *

Model No *

Engine Number *

Make *

Model *

Variant *

Model Year *

Grouping *

Engine Size *

Network *

Internal Memory (GB) *

IMEI Number *

Product Price Band *

Type

Cylinder *

Screen Size

Current Mileage *

Smart

Product Origin *

Invoice *

Manufacturer Warranty Expiry Date *

Manufacturer Warranty Period *

Manufacturer Warrenty Mileage *

Other Info

Plate Number *

Registration Date *

Motor Insurance Company *

Motor Insurance Policy Number *

Motor Insurance Expiry Date *

Motor Insurance Sum Insured *

Policy Excess *

Territory *

Cover Limit Upto *

Bank Finance Amount *

Mortgage Bank *

No. of tires purchased *

Premium for 1 Tire *

Purchased Tire Placement

Purchased Tire & Alloy Placement

Policy Premium Info

Sum Insured *

Gross Premiums *

Excess/Deductible *

Premium Collected *

Total Premium (VAT 5%) *

Repairer *

Upload Documents

Document Type	Upload	Delete Document

Additional Info

Remarks *

Note: I hereby acknowledge that I have received and understood the Terms and Conditions of this Policy

Customer Signature

Date

Customer Name

Place

Premium ID	Premium	Rate	Type	Sum Insured	Premium Tax

Total Premium Tax :-

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