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 :-

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

Replacement Unit

Repairer Defect Report

Customer approval must be obtained to diagnose as required

Is Unit in Service Centre

Yes

No

Dismanteld

Yes

No

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*

Warranty Administration Department Use Only

Policy Maximum Claim liability*

Loss Ratio %

Authority Code*

Total Amount Authorised*

Total Authorised Amount-Policy*

Date*

Time*

Remarks*

Authorised By*

Authorisation Date*

Claim

Policy Number	Certificate Number	User	Service	Product	ProductType	CustomerName	MobileNumber	CustomerId	Claim Amount	PolicyIssueDate	PolicyEffectiveDate	PolicyExpiryDate	Status	Action