Name

Mobile Number

Email ID

Vehicle Number

Nominie Name

Nominie Age

Nominie Relation

Fieldworker Name

Fieldworker Number

Vehicle Type Select Vehicle Type 2 Wheeler 4 Wheeler Other

Petrol/Desiel Select Petrol/Desiel Petrol Desiel Other

Have you claim ever? Select Have you claim ever? Yes No

Do you have pollution certificate? Select Do you have pollution certificate? Yes No

Marital status? Select Marital status? Married Unmarried

Aadhaar Card Front Photo

Aadhaar Card Back Photo

Pan Photo

RC Front Photo

RC Back Photo

Old Policy Document

Pollution Photo

Car Photo