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Registration Number:*
INDIVIDUAL CUSTOMER DETAILS
Ghana Card Number:*
Title:

First Name:*
Other Names:*
Date of Birth:*
Sex:

Phone Number:*
Education Level:

Marital Status:

Digital Address:*
Residential Address:*
Occupation:*
COMPANY DETAILS
TIN Number:*
Business Name:*
Business Sector:*
Business Size:*
Registered Address:*
Year Established:*
Contact Person:*
Contact Person Phone:*
Contact Person Email:*
Business Email Address:*
Business Phone Number:*
Residential Address:*
VEHICLE DETAILS
Policy Type:

Purpose of Usage:*

Number of Vehicle Seats:*
Registration Number:*
Year of Registration:*
Manufacture Year:*
Body Type:

Make:

Value of Vehicle:*
Extra TPPD: (Optional)
Excess Buy Back: (Optional)

Chassis Number:*
Vehicle Color:*
Fuel Type:
Gross Weight:*
Mileage:*
Cubic Capacity:*
Gross Premium:*
Calculation Type:*