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Health Insurance
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New vehicle Policy
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Manufacturer Name:
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Year Of Manufacture:
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Vehicle CC:
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less than 1000
1000 to 1500
above 1500
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Name
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Place
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Email
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Date of First Purchase / Registered
(refer to your RC book)
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Is the current policy in your name ?
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No Claims Bonus as per current policy
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0%
20%
25%
35%
45%
50%
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Have you filed any claim in Expiring Policy?:
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No
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Current Policy expiry date :
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Vehicle Owned By:
Individual
Company
Does the owner have a valid drivers license ?:
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No
Additional Covers:
Value of Electrical / Electronics Accessories:
Value of Non-Electrical Accessories:
Is Fibre glass fuel tank fitted?:
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No
LPG/CNG Kit Cover Type:
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LPG
CNG
Value:
Passenger Seating Capacity(as per RC) :
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1
2
3
4
5
6
7
8
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Passenger Sum Insured :
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10000
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30000
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50000
60000
70000
80000
90000
100000
110000
120000
130000
140000
150000
160000
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180000
190000
200000
Legal liability cover for paid driver(Rs. 25/-)
Discounts:
ARAI approved anti-theft device installed?
Yes
No
Automobile association membership?
Yes
No
Voluntary deductibles:
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25000
5000
10000
15000
Is Vehicle altered for handicapped person?:
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