Policy*

Renew New

Policy required

Proposer*

Individual Corporate

Proposer required

Policy Cover*

Comprehensive Third Party Only Own Damage Only

Policy Cover required

Manufacturer* Select Manufacturer Please Select Manufacture.

Model* Select Model Please Select Model.

Fuel Type* Select Fuel Type Please Select Fuel.

Variant* Select Variant Please Select Variant.

Vehicle Registration Date* Vehicle Invoice Date required

Vehicle Manufacture Date* Vehicle Manufacture Date required

Is Registration Number Is BHARAT Series ? Yes No

Registration Number* Registration Number required Please enter valid Registration Number

External fitted CNG IDV ()* External fitted CNG IDV is required

Electrical Accessories ()

Non-Electrical Accessories ()

Legal Liability to Paid Driver Owner Driver Personal Accident Cover Paid Driver Personal Accident Cover Legal Liability To Employee Cover Unnamed Passenger Personal Accident Cover

Cover Amount Cover Amount required

Restricts Third Party Property Damage* Yes No

TPPD required

Voluntry Excess

Policy Expired ?* Yes No

Policy Expired required

Policy Expired Type* Select Expired Type

Claim in previous year* Yes No

Claim in previous year required

Previous NCB*

Select Previous NCB

Previous Policy Expiry Date*

Previous Policy Expiry Date is required

Previous Policy OD Start Date* Previous Policy OD Start Date is required Please enter valid Previous Policy OD Start Date

Previous Policy OD End Date* Previous Policy OD End Date is required Please enter valid Previous Policy OD End Date

Previous Policy TP Start Date* Previous Policy TP Start Date is required Please enter valid Previous Policy TP Start Date

Previous Policy TP End Date* Previous Policy TP End Date is required Please enter valid Previous Policy TP End Date

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Quotation number :

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CKYC Type One*

CKYC Type One required

Document Type *

Document Type required

Document No.*

Document No. required Please enter valid Document No.

Company Name *

Company Name required

Date of Birth *

Date of Birth is required Please enter valid Date of Birth

Date of Corporation *

Date of Corporation is required Please enter valid Date of Corporation

POI *

POI Type required

POI Photo *

POA *

POA Type required

POA Photo *

POI *

POI Type required

POI Document No. *

POI Document No. required Please enter valid POI Document No.

POI Photo *

POA *

POA Type required

POA Document No. *

POA Document No. required Please enter valid POA Document No.

POA Photo *

Company Type *

Company Type required

Own Damage Period :
To

Liability Period :

Policy Tenure : 1 Year 5 Year

Model Variant :

Reg. No. :

First year of purchase :

Value (IDV) :

NCB : %

Premium :

Salutation*

Salutation required

First Name *

First Name required Please enter valid First Name

Last Name *

Last Name required Please enter valid Last Name

Gender *

Male Female

Gender is required

Date of Birth *

Date of Birth is required Please enter valid Date of Birth

Company Name *

Company Name required Please enter valid Company Name

Mobile No.*

Mobile No. is required Please enter valid Mobile No.

Email *

Email required Please enter valid Email

Relative Salutation*

Realtive Salutation required

Relative First Name *

Relative First Name required Please enter valid Relative First Name

Realtive Last Name *

Realtive Last Name required Please enter valid Relative Last Name

Relationship *

Relation required

Contact Address *

Address is required Please enter valid Address

Marital Status *

Select Marital Status

GSTIN

Note: State code of GSTIN should match with the communication state GSTIN required Please enter valid GSTIN

PAN No.

PAN No. required Please enter valid PAN No.

AADHAR No.

Nominee Full Name *

Nominee Name required Please enter valid Full Nominee Name

Relationship *

Nominee Relation required

Marital Status is Single hence Nominee cannot be the selected option.

Nominee DOB *

Nominee DOB required Please enter valid Nominee Age

Gender *

Male Female

Nominee Gender required

Appointee Full Name *

Appointee Name required Please enter valid Appointee Name

Appointee Relationship *

Appointee Relation required

Previous Insurance Company *

Previous Insurance Company required

Previous Policy No.*

Previous Policy No. required Please enter valid Previous Policy No.

Previous TP Insurance Company *

Previous TP Insurance Company required

Previous TP Policy No.*

Previous TP Policy No. required Please enter valid Previous Policy No.

Chassis No.*

Chassis No. required Please enter valid Chassis No. with minimum 6 characters.

Engine No.*

Engine No. required Please enter valid Engine No. with minimum 6 characters.

PUC NO. *

PUC Expiry Date *

Do you have valid PUC certificate ?

Yes No PUC required

Is Vehicle Financed ?

Agreement Type *

Agreement Type required

Finanacier*

Financier required Please enter valid Financier Name.

Company Name
Proposer Name
Date of Birth
Mobile No.
Email Id
State
City
Contact Address
Pincode
Nominee Name
Nominee Relationship
Nominee Age
Nominee Gender
GSTN
PANNo
Appointee Name
Appointee Relationship

Registration No.
Chassis No.
Engine No.
Model & Variant
Date of Registration
Previous Insurance Company
Previous Policy No.
Previous TP Insurance Company
Previous TP Policy No.
Agreement Type
Finanancer
Finanancer City

I hereby confirm that I have mandated TRUSTegic Insurance Broking LLP. to place my insurance cover and have read and agreed on the Terms and Conditions. Please select Terms & Conditions

TRUSTegic Insurance Broking LLP Head Office - First Floor, C-69, Vibhuti Khand,Gomti Nagar, Lucknow (UP) Pin- 226010

Licence Number – 717, IRDA Direct Broker Code: IRDA/DB791/19 , Valid till: 9th June 2026, LLP Identification Number: AAL-5301, Principal Officer: Mr. Ashutosh Singh (Contact Number - 0522-4104400)

Proposer Communication Details

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Vehicle Details

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1 Basic Detail

Vehicle Details

Accessories

Add-ons

Additional Covers

Discount

Previous Policy Detail

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No Plans Found.

3 CKYC Detail Back to Quotation

4 Proposer Detail Back to CKYC

Proposer Detail

Proposer Communication Details

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Vehicle Details

5 Preview & Payment Change Proposal Detail

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Vehicle Details

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