S.B Insurance Solution Pvt Ltd
Brokers licenced by Insurance Regulatory and Development Authority [I.R.D.A]
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MOTOR INSURANCE

City where car is registered:*

Manufacturer name:*

Model:*

Year of manufacture (yyyy)

Date of first purchase/registration:*(dd/mm/yyyy)

Previous policy start date (dd/mm/yyyy)

Previous policy expiry date (dd/mm/yyyy)
No claim bonus in previous policy
Claims made in expiring policy
FOR DISCOUNTS
Is ARAI approved anti theft device installed
Automobile Association Membership
ADDITIONAL COVERS  
Value of Electric Accessories(in Rs.)
Value of Non Electric Accessories(in Rs.)
Accident cover for unnamed passengers
Legal liablity cover for paid driver
Value of LPG/CNG kit if any(in Rs.)

OWNERS CONTACT INFORMATION:

Vehicle registered in the name of:company/individual:

Full Name*
Address
City

Telephone No
Mobile No*

Email*
   
 
 
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Insurance is the subject matter of the solicitation
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