General Information

Policy Number*

Creation Date

Location*

Group*

Issued By*

Sales Consultant*

User*

Product*

Product Type*

Customer Type*

Currency*

Policy Effective Date*

Policy Expiry Date*

Customer Information

Title

First Name*

Middle Name*

Last Name*

Full Name

Gender

Company Name

ID Type*

ID Number*

ID Expiry*

Date of Birth*

Mobile Number*

Alt Mobile Number*

Email ID*

P O Box*

Emirate*

Nationality*

Vehicle Info

Vehicle Sales Type*

Vehicle Make*

Vehicle Model*

Variant*

CC*

Cylinder*

Sold Date*

Vehicle Invoice Value*

Body Type*

Colour*

Model Year*

Chassis Number*

Engine Number*

Kilometres*

Manufacturer Warranty Expiry Date*

Manufacturer Warranty Cover*

Product Info

Product Make *

Product Modal *

Variant *

Product Grouping *

Modal Year *

Product Serial No *

Network *

Internal Memory (GB) *

IMEI Number *

Product Sales Price *

Product Price Band *

Screen Type

Screen Size

Smart

Product Origin *

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 *

Premium Collected *

Total Premium(VAT 5%) *

Uploaded Documents

Document	Status	Delete
Document 1	Pending	delete

Additional Info

Remarks*

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

Cancel Type

Select Cancel Type

Customer Signature

Date

Customer Name

Place

Policy Details

Enter Policy Number

Service Center Details

Reference Number

Company Name*

Date*

Fax No.

Tel No.*

Job Title*

Service Advisor Contact Number.*

Service centre Co. Mail ID*

Service Advisor Name*

Product And Unit Details

Customer name

Policy Number*

Purchase Date

Contact Tel No*

Product

Product Type*

Unit Make

Model

Plate Number

Chassis Number

Policy Expiry Date

Loss Details

Date Of Loss

Cause Of Loss

Location Of Loss

Kilometers At Loss

Count Of Loss

Total Count Of Loss

Total Claimed Amount

Replacement Unit

Repairer Defect Report

Customer approval must be obtained to diagnose as required

Is Unit in Service Centre

Yes

Dismanteld

Yes

Details

Claims Estimate – Service and Repair

Parts Cost*

Discount in Parts %*

Net Parts Cost*

Labour Charges per Hour

No. Of Hours

Total Labour Charges*

Discount on Labour %*

Net Labour Charges*

Gross Claim Request Amount*

Max Policy Benefit Amount

TP Benefit Amount

Approved Benefit Amount*

Retailer/Customer Share %*

Retailer/Customer Amount*

Net Claim Request Amount*

Policy Excess *

Policy Excess Amount*

Final Claim Amount*

Remarks*

Upload Documents

Document	Staus	Delete
Document 1	delete

Document Type	Upload	Delete Document

Warranty Administration Department Use Only

Policy Maximum Claim liability*

Loss Ratio %

Authority Code*

Total Amount Authorised*

Date*

Time*

Remarks*

Authorised By*

Authorisation Date*

Id	Policy Number	Certificate No	CIN	User	Service	Product	Product Type	Customer Name	Mobile Number	Customer ID	Total Premium	Claim Amount	Policy Issue Date	Policy Effective Date	Policy Expiry Date	UIN	Status	Action

: - Inforce
: - Insured
: - In Process
: - Need Correction
: - Rejected
: - Approved

Chart