Policy*

Renew New

Policy required

Proposer*

Individual Corporate

Proposer required

Policy Cover*

Comprehensive Third Party Only

Policy Cover required

Vehicle Type* Select Vehicle Type Please Select Vehicle Type.

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

Registration Number* Registration Number required Please enter valid Registration Number

Permit Type* Please Select Permit Type.

Manufacturing Built Type* Please Select Manufacturing Built Type.

Zero Dep Road Side Assitance Zero Dep in previous policy

Owner Driver Personal Accident Cover

IMT23 Cover

Legal Liability to Paid Driver

Legal Liability To Cleaners

Legal Liability To Employees

Legal Liability To Unnamed Passenger

Unnamed Paid Driver Personal Accident Cover

Unnamed Passenger Personal Accident Cover

Unnamed Cleaner Personal Accident Cover

Unnamed Conductor Personal Accident Cover

Geographical Extension

Geog. Extn. Countries Select as least one country

CNG - IMT25 Cover

CNG Value - IMT 25 () CNG Value is required

Electrical Accessories - IMT 24

Electrical Accessories - IMT 24 () Electrical Accessories is required

Non Electrical Accessories - IMT 24

Non Electrical Accessories - IMT 24 () Non Electrical Accessories is required

Restricts Third Party Property Damage* Yes No

TPPD required

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

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Quotation number :

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CKYC Type One *

CKYC Type One required

CKYC Type One*

CKYC Type One required

Document Type*

Document Type required

Document No.*

Document No. required Please enter valid Document No.

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

POA Photo *

Profile Photo *

Father Name*

POI*

POI Type required

POI Photo*

POA*

POA Type required

POA Photo*

Own Damage Period :
To

Liability Period :

Policy Tenure : 1 Year 5 Year

Model Variant :

Reg. No. :

NCB : %

year of purchase :

Premium :

Value (IDV) :

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

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 Age 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

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

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.

Motor No.*

PUC NO. *

PUC Expiry Date *

Bank Name*

Bank Name required

Account Number*

Account Number required

IFSC code*

IFSC Code required IFSC Code Length should be 11

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 EPIX INSURANCE BROKERS PRIVATE LIMITED. to place my insurance cover and have read and agreed on the Terms and Conditions. Please select Terms & Conditions

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Form

Are you a Business ?

Yes

Registered Mobile No.*

Verify Using OTP*

Also you can verify using Chassis No. OR Engine No.

Chassis No.*

Engine No.*

Product Type Bike Car Commercial

Reg. No.*

Chassis No.*

Engine No.*

Proposer Details

Proposer Communication Details

Nominee Details

Vehicle Details

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1 Basic Detail

Vehicle Details

Add-ons

Additional Covers

Previous Policy Detail

2 Your Insurance Quotation Change Basic Detail

No Result Found.

No Plans Found.

3 CKYC Detail Back to Quotation

4 Proposer Details Back to CKYC

Proposer Details

Proposer Communication Details

Nominee Details

Vehicle Details

5 Preview & Payment Change Proposal Detail

Proposer Details

Vehicle Details

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