Choice Connect | Registration

Personal Details

Customer Name *

Customer Email Id *

Customer Mobile *

Alternate Customer Mobile

Alternate Email

Pin Code *

State *

District *

PAN Number

Referral Code *

Policy Types

Policy Type *

New Bike Insurance Renew Bike Insurance

Vehicle Details

Registration No *

Manufacturing Year *

Registration Date *

RTO *

Make *

Model *

Variant *

Chassis No.

Engine No.

Previous Policy Details

Do you have a Valid Previous Year Policy Copy? *

Yes No

Previous Policy Type *

Comprehensive OD TP

Previous Policy *

Existing Insurer *

Previous Policy Expiry Date *

Is ownership change in last 12 months? *

Yes No

Have You Made Any Claims in Your Expiring Policy? *

Yes No

NCB in Your Existing Policy? *

NCB Earned *

Other Details

Remark