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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SNO	Dealer Name	Dealer Location	User Name	User Id	Sales Type	Sales Consultant	Customer Name	Nationality	Customer Contact No	Product Type	Product	Period of Cover (months)	Vehicle Make	Vehicle Model	Model year	Chassis No	Invoice Value	Policy No	Oman Insurance Reference No	Policy Issue Date	Policy Effective Date	Policy Expiry Date	OIC Net Premium	OIC Net Premium (Incl. 5% VAT)	Messages