Name of Insured
ADDRESS
EMAIL
POLICY NO
SUM INSURED
MAKE & MODEL
REGISTRATION NUMBER
CHASSIS NUMBER
YEAR OF MANUFACTURE
GLAZING (INSCRIBE REG./INDEX MARK ON GLASS) YesNo
COLOUR
SPEEDOMETER READING
ANY OTHER SPECIAL FEATURE
RECOMMEDATION
OFFICER’S NAME
INSURED/REPRESENTATIVE’S
SIGNATURE
OFFICER's SIGNATURE
DATE
