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Motor Insurance Request

Please provide the following information correctly

Auto Secure Plan (Private Car Insurance)
1.	Car owner's name:	First Name: Last Name
2.	Contact e-mail address:
3.	Contact phone no:
4.	Vehicle Make (Manufacturer name):
5.	Vehicle Model:
6.	Vehicle year of manufacture:
7.	Have you made a claim this year:	Yes No
8.	Do you need personal accident insurance?	Yes No


9.	Do you need insurance for electronic Accessories?	Yes No
10.	We will insure your vehicle at:	(INR) Customer can vary this value by +/-10%

Auto Secure Plan (Private Car Insurance)