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Please Select 'Vehicle Class', 'Vehicle Manufacturer' and 'Make' in respective order.
Risk Details
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Motor
Business Source :
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Business Channel
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Vehicle Class
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Miscellaneous Vehicle Type
Covers Type
Long Term Cover Period Applicable Only For New Business.
Vehicle Registration State
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Vehicle Manufacturer
*
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Make
*
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Proposal Number :
0
Transaction NO :
Reference Date :
Customer ID :
POLICY PERIOD
Policy Start Date :
Policy Expiry Date :
Business Type
New
Renewal
VEHICLE DETAILS
New Vehicle
Registration Number
Vehicle Model
Body Type
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Date Of 1st Registration
*
Make Month
*
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Make Year
*
Date Of 1st Purchase/Delivery
Engine Number
*
Chassis Number
*
Registered Seating Capacity
*
HP/Cubic Capacity/KWs
Fuel Type
*
select
Petrol
Diesel
LPG/CNG
Battery
Electricity
Hydrogen
Hybrid Electric
Vehicle Color
FASTAG ID
Whether Valid PUC is available for the Vehicle ?
*
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Yes
No
Whether Vehicle is plying in Delhi – NCR Region ?
*
select
Yes
No
INSURED DETAILS
Existing Customer?
Yes
No
Customer ID
Proposal date
Transfer Vehicle(NCB Certified)
Previous Company Name
Select
UNITED INDIA INSURANCE CO.LTD.
NATIONAL INSURANCE CO.LTD.
THE NEW INDIA ASSURANCE CO. LTD.
THE ORIENTAL INSURANCE CO. LTD.
Previous Policy No
*
Previous Policy Start Date
*
Previous Policy Expiry Date
*
Previous NCB
0%
20%
25%
35%
45%
50%
Any Previous Claim
No
Yes
Inspected By
*
Inspection Date
*
Inspection Time
*
HH
MM
Inspection Remarks
*
Inspection related fields are mandatory only for break-in insurance
Insured Type
*
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Paid Up Capital
Upto Rs. 10 Crores
From Rs. 10 to 25 Crores
More than Rs. 25 Crores
Insured Title
*
Mr
Mrs
Ms
Ot
M/S
Insured Name
*
Address
*
Gender
*
Pincode
*
State
*
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District
*
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e Insurance Account Number
Repository Name
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IS UIN
GSTIN Number/UIN Number
CKYC NO
TAN No
GST TDS Reg No
Landline
(+91)
Mobile
*
(+91)
Either Landline or Mobile is Mandatory
Email
*
Fax
Date Of Birth
*
Occupation
*
Others
Aadhaar No
Pan No
Enrolment No
Enrolment Date
Enter Aadhaar No. or Aadhaar Enrolment No. and Enrolment Date.
Agree to receive Promotional/Renewal SMS/Email from UIIC
INSURED DECLARED VALUE / VEHICLE ZONE
RTA
*
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Zone
*
Valuation Basis
IDV
INVOICE
IDV/Invoice Value
Electrical
Non Electrical
LPG (Inbuilt
)
CNG (Inbuilt
)
Glass Tank
No. of Trailer
AAI MEMBERSHIP / FINANCIER / POLICY PERIOD
Financier
Financier State
Financier District
Financier Name
Agreement Type
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OD Discount %
Total IDV
OD Premium
TP Premium
Service Tax/GST
Stamp Duty
Net Premium
TOTAL (₹)
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