New Workshop Registration

Dealer Code*

Workshop Code*

Workshop Name*

Dealer Name*

Workshop address*

GSTIN*

Pan Card Number*

Contact Person*

Contact Number*

Alternate Contact Number

Primary Email Id*

Secondary Email Id*

Regional Sales Manager-Allianz

Area Office-HMC*

Zone* Please select Zone

State* Please select the State

City* Please select the City

PINCODE*

Bank Name*

Bank Account No*

IFSC Code*

Beneficiary name*

Bank Branch Address*