| Customer Informaiton |
| CNIC No |
* |
CNIC Issuance Date |
* |
| Name |
* |
Date of Birth |
* |
| Father / Husband Name |
*
|
Gender |
|
| Telephone |
|
City |
|
| Mobile |
* |
Email Address |
* |
| Source of Income |
|
Profile of Customer |
* |
| NTN No |
|
Politically Exposed Person |
|
Related to Politically Exposed Person |
|
|
| Residential Address |
|
| Policy Informaiton |
| Product | |
Policy Start Date |
|
| Policy Coverage |
|
Vehicle Manufacture |
*
|
| Vehicle Make | *
|
Vehicle Model |
|
| Vehicle Color |
*
|
Use of Vehicle |
|
| Tracker Device |
* |
Tracker Vendor |
|
| Description |
|
| Accessories |
|
Accessories value Rs. |
|
| Invoice Price (Rs.) |
*
Rate%
|
Filer: |
*
|
| Premium Informaiton |
| Premium Payable (Rs.) |
|
Vehicle Engine No | |
| Vehicle Chassis No |
|
Vehicle Registration No | |
|
|
| |
| |
|
