Motor Insurance Inquiry Form

Please take a moment to fill out this form—just 1 minute—to help us get to know you

better so we can offer the best possible options tailored to your needs.

Full Name

Phone No *

Email *

What type of vehicle do you want to insure?

Car

Two-Wheeler

Commercial Vehicle

Other**

Is this a new policy or a renewal?

New Policy

Renewal

Not Sure

What type of coverage are you looking for?

Third-Party Only

Comprehensive

Not Sure – Need Guidance

Have you claimed insurance in the past year?

Yes

No

Would you like to be contacted by a Coverwise advisor?

Yes – Call Me

Yes – WhatsApp Me

No – I’ll Get in Touch Later

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