5

‫ﺑﻬﺬﺍ نﺸﻬﺪ ﺑ ﺄنﻨﺎ ﺃﺻﺪﺭن ﺎ ﻭﺛﻴﻘﺔ ﺗ ﺄﻣﻴﻦ ﻟﻠﺴﻴ ﺎﺭﺓ ﺍﻟﻤﻮﺻﻮﻓﺔ ﺃﺩن ﺎﻩ ﻭﻓﻘ ﺎ ﻷﺣﻜ ﺎﻡ ﺗ ﺄﻣﻴﻦ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ ﺍﻟﻤﺪنﻴﺔ‬
‫ﺗﺠ ﺎﻩ ﺍﻟﻐﻴﺮ (ﺍﻟﻤﺮﻛﺒ ﺎﺕ) ﻓ ي ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬
This is to certify that a policy of ins urance has been is s ued in res pect of
the v ehicle details below as per s tatutory third party liability requirem ents of
the kingdom of S audi Arabia

CERTIFICATE OF MOTOR VEHICLE ‫ﺍﻟﺴﻴ ﺎﺭﺓ ﺗ ﺄﻣﻴﻦ ﺷﻬ ﺎﺩﺓ‬

INSURANCE NO : 20/VP/120521/0/0 20/VP/120521/0/0 : ‫ﺭﻗﻢ ﺍﻟﺘﺄﻣﻴﻦ‬
INSURED NAME : FAHAD AJLAN ABDULLAH ALAJLAN ‫ فهد عجالن عبدالله العجالن‬: ‫ﺇﺳﻢ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
MOTOR VEHICLE DETAILS : : ‫ﺗف ﺎﺻﻴﻞ ﺍﻟﺴﻴ ﺎﺭﺓ‬
Registration No : 4226 ‫د د ح‬ 4226 ‫ د د ح‬: ‫ﺭﻗﻢ ﺍﻟﻠﻮﺣﺔ‬
Chassis No : VF1LZLGT9GR576663 VF1LZLGT9GR576663 : ‫ﺭﻗﻢ ﺍﻟﻬﻴﻜﻞ‬
Make : ‫رينو‬ ‫ رينو‬: ‫نﻮﻉ ﺍﻟﺴﻴﺎﺭﺓ‬
Year : 2016 2016 : ‫ﺳﻨﺔ ﺍﻟﺼﻨﻊ‬
Custom Card ID : : ‫ﺭﻗﻢ ﺍﻟﺒﻄﺎﻗﺔ ﺍﻟﺠﻤﺮﻛﻴﺔ‬
PERIOD OF INS URANCE: From: 03-11-2021 :‫ﻣﻦ‬ To: 02-11-2022 :‫ﺇﻟى‬ : ‫ﻣﺪﺓ ﺍﻟﺘ ﺄﻣﻴﻦ‬
Corresponding to :
Subject always to the Limits of Liability of 10,000,000 S.R. as
provided in the Policy arising out of the use of the insured Motor ‫ ﺭﺱ ﺍﻟﻤﺒﻴﻨﺔ ﻓي ﺍﻟﻮﺛﻴﻘﺔ ﻭﺍﻟﻨﺎﺗﺠﺔ‬١٠,٠٠٠,٠٠٠ ‫ﻭﺫﻟﻚ ﺿﻤﻦ ﺣﺪﻭﺩ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ‬
Vehicle within Saudi Arabia.
This Certificate is deemed to be a guarantee for payment for all ‫ﻹﺳﺘﺨﺪﺍﻡ ﺍﻟﺴﻴﺎﺭﺓ ﺍﻟﻤﺆﻣﻨﺔ ﺩﺍﺧﻞ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺗﻌﺘﺒﺮ ﻫﺬﻩ‬
amounts which the Insured Owner and/or the Authorized Driver at
the time of the accident shall become legally liable to pay as ‫ﺍﻟﺸﻬﺎﺩﺓ ﻛﻀﻤﺎﻥ ﻟﺪﻓﻊ ﻛﺎﻓﺔ ﺍﻟﻤﺒﺎﻟﻎ ﺍﻟﺘي ﻳﻜﻮﻥ ﺍﻟﻤﺎﻟﻚ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﺃﻭ‬
compensation for
(a) Death or bodily injury sustained by any person including ‫ ﺍﻟﻮﻓﺎﺓ ﺃﻭ ﺍﻹﺻﺎﺑﺔ ﺍﻟﺒﺪنﻴﺔ ﺍﻟﺘي ﺗﺤﺪﺙ ﻷﻱ ﺷﺨﺺ ﺑﻤﺎ ﻓي ﺫﻟﻚ ﺭﻛﺎﺏ ﺍﻟﺴﻴﺎﺭﺓ‬.1
passengers of the vehicle
(b) Damage to third party property outside the Insured Vehicle ‫ ﺗﻠﻒ ﻣﻤﺘﻠﻜﺎﺕ ﺃﻱ ﻃﺮﻑ ﺛﺎﻟﺚ ﺧﺎﺭﺝ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﺆﻣﻨﺔ‬.2
S IGNED: :‫ﺍﻟﺘﻮﻗﻴﻊ‬

Gary M.Lew in ‫ ﻟﻴﻮﻳﻦ‬.‫ﺟ ﺎﺭ ﻱ ﻡ‬

Chief Ex ecutiv e Officer ‫ﺍﻟﺮﺋﻴ ﺲ ﺍﻟﺘﻨفﻴﺬ ﻱ‬

IMPORTANT ‫ﻣﻼﺣﻄ ﺎﺕ ﻫ ﺎﻣﺔ‬

1.This certificate of Insurance and Policy is valid only for the
Insured Owner and the authorized Driver at the time of Accident ‫ ﺇﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺘﺄﻣﻴﻦ ﻫﺬﻩ ﺻﺎﻟﺤﺔ ﻓﻘﻂ ﻟﻠﻤﺎﻟﻚ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻭﺍﻟﺴﺎﺋﻖ ﺍﻟﻤﺨﻮﻝ ﻟﻪ‬. 1
and is NOT transferable without prior consent of the Insurance ‫ﺑﺎﻟﻘﻴﺎﺩﺓ ﻓي ﺣﺎﻟﺔ ﻭﻗﻮﻉ ﺣﺎﺩﺙ ﻭﻫي ﻏﻴﺮ ﻗﺎﺑﻠﺔ ﻟﻠﺘﺤﻮﻳﻞ ﺑﺪﻭﻥ ﻣﻮﺍﻓﻘﺔ‬
Company.
‫ﻣﺴﺒﻘﺔ ﻣﻦ ﻗﺒﻞ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
2.Any Accident must be notified to the Insurance Company
immediately. .‫ ﻋﻨﺪ ﻭﻗﻮﻉ ﺃﻱ ﺣﺎﺩﺙ ﻳﺠﺐ ﺇﺧﻄﺎﺭ ﺍﻟﺸﺮﻛﺔ ﻓﻮﺭﺍ‬.2

AXA Cooperative Insurance Company CR-No 1010271203 P.O.Box 753 Al Riyadh 11421, Kanoo Tower, King Abdul Aziz ‫ ﺍﻟﻄﺎﺑﻖ ﺍﻟﺜﺎني‬،‫ ﺷﺎﺭﻉ ﺍﻟﻤﻠﻚ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ‬،‫ ﺑﺮﺝ ﻛﺎنﻮ‬11421 ‫ ﺍﻟﺮﻳﺎﺽ‬753 ‫ ﺹ ﺏ‬1010271203 : ‫ﺷﺮﻛﺔ ﺃﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭني ﺱ ﺕ‬
Road,2nd Floor, Al Riyadh, KSA.
Telephone :8001160020 & 8001164845 8001164845 & 8001160020 : ‫ ﻫﺎﺗﻒ‬00966118140874 :‫ﻓﺎﻛﺲ‬
Fax : 00966 (11) 4780418 motorclaims.reg-ksa@axa-cooperative.com :‫ ﺍﻟﺒﺮﻳﺪ ﺍالﻟﻜﺘﺮﻭني‬www.axa-cooperative.com :‫ﺍﻹﻟﻜﺘﺮﻭني ﺍﻟﻤﻮﻗﻊ‬
Email : motorclaims.reg-ksa@axa-cooperative.com Website :www.axa-cooperative.com
A company registered with the Ministry of Commerce and Industry of the Kingdom of Saudi Arabia under Commercial ‫ ﻭﺗﺤﻤﻞ ﺭﺧﺼﺔ ﺗﺄﻣﻴﻦ ﺭﻗﻢ‬1010271203 ‫ﺷﺮﻛﺔ ﻣﺴﺠﻠﺔ ﻓي ﻭﺯﺍﺭﺓ ﺍﻟﺼﻨﺎﻋﺔ ﻭﺍﻟﺘﺠﺎﺭﺓ ﻟﻠﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﺑﺴﺠﻞ ﺗﺠﺎﺭﻱ ﺭﻗﻢ‬
Registration No. 1010271203 and holding Insurance license No. TMN/25/20101 issued by the Saudi Arabian Monetary ‫ﺻﺎﺩﺭﺓ ﻣﻦ ﻗﺒﻞ ﻣﺆﺳﺴﺔ ﺍﻟﻨﻘﺪ ﺍﻟﻌﺮﺑي ﺍﻟﺴﻌﻮﺩﻱ‬TMN/25/20101
Agency
Motor Third Party Liability ‫ ﺍﻟﻤﺴﺆﻭﻟﻴ ﺔ ﺍﻟﻤﺪنﻴ ﺔ ﺿﺪ ﺍﻟﻐﻴﺮ‬- ‫ﺍﻟﻤﺮﻛﺒ ﺎﺕ‬
Policy S chedule ‫ﺟﺪﻭﻝ ﻭﺛﻴﻘ ﺔ ﺍﻟﺘ ﺄﻣﻴﻦ‬

‫ﺍﻟﻮﺛﻴﻘﺔ ﺭﻗﻢ‬ ‫نﻮﻉ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬

20/VP/120521/0/0 Individual
Policy No Ty pe of the Ins ured

Ins ured Details ‫ﺑﻴ ﺎنﺎﺕ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬

‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﺒﺮﻳﺪ ﻱ‬ ‫ﺭﻗﻢ ﻫﻮﻳﺔ ﺍﻟﻤﻮؤﻣﻦ ﻟﻪ‬
12544 – ‫ – الرياض‬SAUDI ARABIA 1044881389
Mailing Addres s Ins ured’s ID
‫ﺍﺳﻢ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
‫فهد عجالن عبدالله العجالن‬
3228 – ‫– الرياض – عرقة – عبدالله المنيعي‬ ‫ﻋﻨﻮﺍﻥ ﺍﻟﺴﻜﻦ‬ Name of the Ins ured
– 12544 Res idential Addres s ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
966505460713
Telephone No.
Vehicle Details ‫ﺑﻴ ﺎنﺎﺕ ﺍﻟﻤﺮﻛﺒﺔ‬
‫ﺍﺳﻢ ﻣ ﺎﻟﻚ ﺍﻟﻤﺮﻛﺒﺔ‬ ‫ﺭﻗﻢ ﻫﻮﻳﺔ ﻣ ﺎﻟﻚ ﺍﻟﻤﺮﻛﺒﺔ‬
‫فهد عجالن عبدالله العجالن‬ 1044881389
Vehicle Ow ner Name ID No. of Vehicle Ow ner
‫ﺭﻗﻢ ﺍﻟﻬﻴﻜﻞ‬ ‫ﺭﻗﻢ ﻟﻮﺣﺔ ﺍﻟﻤﺮﻛﺒﺔ‬
VF1LZLGT9GR576663 4226 ‫د د ح‬
Chas s is No. Vehicle Plate No
‫ﺗ ﺎﺭﻳخ ﺍن ﺘ ﻬ ﺎء ﺭﺧﺼﺔ ﺍﻟﺴﻴﺮ‬ ‫ﻟﻮﻥ ﺍﻟﻤﺮﻛﺒﺔ‬
07-01-1445 ‫فضي‬
Regis tration ex piry date Vehicle Color
‫ﺭﻗﻢ ﺍﻟﺒﻄﺎﻗﺔ ﺍﻟﺠﻤﺮﻛﻴﺔ‬ ‫نﻮﻉ ﻫﻴﻜﻞ ﺍﻟﻤﺮﻛﺒﺔ‬
‫ باب‬4 ‫سيارة صغيرة‬
Cus tom ID No. Vehicle Body Ty pe
‫ﺳﻨﺔ ﺍﻟﺼﻨﻊ‬ ‫ﻣ ﺎﺭﻛﺔ ﺍﻟﻤﺮﻛﺒﺔ‬
2016 ‫رينو‬
Year of Manufacture Vehicle Brand
‫ﻏﺮ ﺽ ﺍالﺳﺘﻌﻤ ﺎﻝ‬ ‫ﻣﻮﺩﻳﻞ ﺍﻟﻤﺮﻛﺒﺔ‬
Private ‫فلونس‬
Purpos e of Us e Vehicle Model
‫ ﺿﺪ ﺍﻟﻐﻴﺮ ﻓﻘﻂ‬- ‫ال ﻳﻄﺒﻖ‬ ‫ﻣﺒﻠﻎ ﺍﻟﺘ ﺄﻣﻴﻦ‬ ‫نﻮﻉ ﺗﺴﺠﻴﻞ ﺍﻟﻤﺮﻛﺒﺔ‬
‫خصوصي‬
N/A – TPL Only Ins ured Value Vehicle regis tration ty pe
Ty pe of Cov erage PRIVATE CAR – THIRD PARTY ‫ﺗﺄﻣﻴﻦ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ ﺍﻟﻤﺪنﻴﺔ ﺿﺪ ﺍﻟﻐﻴﺮ‬ ‫نﻮﻉ ﺍﻟﺘفﻄﻴﺔ‬
Section 2 ٢ ‫ﺍﻟﻘﺴﻢ‬
The company's liability in any one ‫ﻣﺴﺆﻭﻟﻴﺔ ﺍﻟﺸﺮﻛﺔ ﻓي ﺍﻟﻮﺍﻗﻌﺔ ﺍﻟﻮﺍﺣﺪﺓ‬
occurrence in respect of bodily injury ‫ﺑﺎﻟﻨﺴﺒﺔ ﻟﻸﺿﺮﺍﺭ ﺍﻟﺠﺴﺪﻳﺔ ﻭ ﺍﻷﺿﺮﺍﺭ ﺍﻟﻤﺎﺩﻳﺔ‬
and property damage shall not exceed 10,000,000 ‫ﻟﻦ ﺗﺘﺠﺎﻭﺯ ﻣﺒﻠﻐﺎ ﺍﺟﻤﺎﻟﻴﺎ ﻗﺪﺭﻩ‬
Policy Lim its ‫ﺣﺪﻭﺩ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ‬
an amount of 10,000,000 Riyals (Ten ‫ﺭﻳﺎﻝ )ﻋﺸﺮﺓ ﻣﻼﻳﻴﻦ ﺭﻳﺎﻝ ﺳﻌﻮﺩﻱ( ﻛﺤﺪ ﺃﻗﺼى‬
Million Saudi Riyals) as a maximum.

Roadside Assistance ‫ﺍﻟﻤﺴﺎﻋﺪﺓ ﻋﻠى ﺍﻟﻄﺮﻳﻖ‬

‫غير مشمول ة‬
Personal Accident – Driver ‫غير مشمول ة‬ ‫ ﺍﻟﺴﺎﺋﻖ‬- ‫ﻣﻨفﻌﺔ ﺍﻟﺤﻮﺍﺩﺙ ﺍﻟﺸﺨﺼﻴﺔ‬
Optional Cov ers ‫ﺍﻟﺨﻴ ﺎﺭﺍﺕ ﺍﻹﺿﺎﻓﻴﺔ‬
Personal Accident – Passenger ‫غير مشمول ة‬ ‫ ﺍﻟﺮﻛﺎﺏ‬- ‫ﻣﻨفﻌﺔ ﺍﻟﺤﻮﺍﺩﺙ ﺍﻟﺸﺨﺼﻴﺔ‬
‫مشمول ة‬
Cover for driver below 21 years ‫ ﺳﻨﺔ‬21 ‫ﺗﻐﻄﻴﺔ ﺃﻱ ﺳﺎﺋﻖ ﺩﻭﻥ‬

AXA Cooperative Insurance Company CR-No 1010271203 P.O.Box 753 Al Riyadh 11421, Kanoo Tower, King Abdul Aziz ‫ ﺍﻟﻄﺎﺑﻖ ﺍﻟﺜﺎني‬،‫ ﺷﺎﺭﻉ ﺍﻟﻤﻠﻚ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ‬،‫ ﺑﺮﺝ ﻛﺎنﻮ‬11421 ‫ ﺍﻟﺮﻳﺎﺽ‬753 ‫ ﺹ ﺏ‬1010271203 : ‫ﺷﺮﻛﺔ ﺃﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭني ﺱ ﺕ‬
Road,2nd Floor, Al Riyadh, KSA.
Telephone :8001160020 & 8001164845 8001164845 & 8001160020 : ‫ ﻫﺎﺗﻒ‬00966118140874 :‫ﻓﺎﻛﺲ‬
Fax : 00966 (11) 4780418 motorclaims.reg-ksa@axa-cooperative.com :‫ ﺍﻟﺒﺮﻳﺪ ﺍالﻟﻜﺘﺮﻭني‬www.axa-cooperative.com :‫ﺍﻹﻟﻜﺘﺮﻭني ﺍﻟﻤﻮﻗﻊ‬
Email : motorclaims.reg-ksa@axa-cooperative.com Website :www.axa-cooperative.com
A company registered with the Ministry of Commerce and Industry of the Kingdom of Saudi Arabia under Commercial ‫ ﻭﺗﺤﻤﻞ ﺭﺧﺼﺔ ﺗﺄﻣﻴﻦ ﺭﻗﻢ‬1010271203 ‫ﺷﺮﻛﺔ ﻣﺴﺠﻠﺔ ﻓي ﻭﺯﺍﺭﺓ ﺍﻟﺼﻨﺎﻋﺔ ﻭﺍﻟﺘﺠﺎﺭﺓ ﻟﻠﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﺑﺴﺠﻞ ﺗﺠﺎﺭﻱ ﺭﻗﻢ‬
Registration No. 1010271203 and holding Insurance license No. TMN/25/20101 issued by the Saudi Arabian Monetary ‫ﺻﺎﺩﺭﺓ ﻣﻦ ﻗﺒﻞ ﻣﺆﺳﺴﺔ ﺍﻟﻨﻘﺪ ﺍﻟﻌﺮﺑي ﺍﻟﺴﻌﻮﺩﻱ‬TMN/25/20101
Agency
Nam es of authorized driv ers below ‫ﺃﺳﻤ ﺎء ﺍﻟﺴﺎﺋﻘﻴﻦ ﺍﻟﻤﺠ ﺎﺯﻳﻦ ﺍﻟﺬﻳﻦ ﺗﻘﻞ‬
21 Years ‫ ﺳﻨﺔ‬21 ‫ﺃﻋﻤ ﺎﺭﻫﻢ ﻋﻦ‬

Geographical Lim its S ection 2 - KS A ‫ – ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬2 ‫ﺍﻟﻘﺴﻢ‬ ‫ﺍﻟﺤﺪﻭﺩ ﺍﻟﺠﻐﺮﺍﻓﻴ ﺔ‬

The Insured shall only use the vehicle for ‫ﻳﺠﺐ ﻋﻠى ﺍﻟﻤﺴﺘﺨﺪﻡ ﻟﻪ ﺃال ﻳﺴﺘﺨﺪﻡ ﺍﻟﻤﺮﻛﺒﺔ ﺇال‬
Lim itation of Us e ‫ﻗﻴﺪ ﺍالﺳﺘﻌﻤ ﺎ ﻝ‬
the specified purpose ‫ﻟﻠﻐﺮﺽ ﺍﻟﻤﺮﺧﺺ ﻣﻦ ﺃﺟﻠﻪ‬
Basic Premium 932.33 ‫ﺍﻟﻘﺴﻂ ﺍﻷﺳﺎﺳي‬
Optional Covers 839.10 ‫ﺍﻟﺨﻴﺎﺭﺍﺕ ﺍالﺿﺎﻓﻴﺔ‬
Prem ium Am ount No Claim Discount 93.23 ‫ﺍﻟﺨﺼﻢ‬ ‫ﻣﺒﻠﻎ ﺍﻟﻘﺴﻂ‬
Claim Loading ‫ﺗﺤﻤﻴﻞ ﺍﻟﻤﻄﺎﻟﺒﺔ‬
Total Prem ium 1929.92 ‫ﺍﻟﻘﺴ ﻂ ﺍﻹﺟﻤ ﺎﻟ ي‬

Com m is s ion Am ount 38.6 ‫ﻣﺒﻠﻎ ﺍﻟﻌﻤﻮﻟﺔ‬

S tandard Ex ces s SAR 0.00 ‫ﻣﺒﻠﻎ ﺍﻟﺘﺤﻤﻞ‬

Young/Nov ice Driv er ‫ﻣﺒﻠﻎ ﺍﻟﺘﺤﻤﻞ ﺍالﺿ ﺎﻓ ي ﻷ ﻱ ﺳ ﺎﺋ ﻖ ﻣﺒﺘﺪ ﺉ ﺃﻭ‬

Not Applicable ‫ﻏﻴﺮ ﻣﺤﺪﺩ‬
Ex ces s ‫ ﺳﻨﺔ‬25 ‫ﺩﻭﻥ‬
Date 02-11-2021 ‫ﺍﻟﺘ ﺎﺭﻳخ‬
Policy Is s ue Date ‫ﺗ ﺎﺭﻳخ ﺇﺻﺪﺍﺭ ﺍﻟﻮﺛﻴﻘﺔ‬
Tim e 21:19 ‫ﺍﻟﻮﻗت‬
From Wednesday ‫ﻣﻦ ﻳﻮﻡ‬
Date 03-11-2021 ‫ﺍﻟﻤﻮﺍﻓ ﻖ‬
Tim e 00:01 ‫ﺍﻟﺴﺎﻋﺔ‬
Cov erage Period ‫ﻓﺘﺮﺓ ﺍﻟﺘﻐﻄﻴﺔ‬
To WednesdayE ‫ﺇﻟ ى ﻳﻮﻡ‬
Date 02-11-2022 ‫ﺍﻟﻤﻮﺍﻓ ﻖ‬
Tim e 23:59 ‫ﺍﻟﺴﺎﻋﺔ‬
Racing Ex clus ion claus e Racing Ex clus ion Claus e
Racing exclusion clause Racing exclusion clause
Vehicle ow ners hip ‫ﺷﺮط ﻣﻠﻜﻴﺔ ﺍﻟﻤﺮﻛﺒ ﺔ‬
The insured shall remain throughout the period ‫ﻳﺠﺐ ﺃﻥ ﻳﺒﻘى ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻭﻃﻮﺍﻝ ﻓﺘﺮﺓ ﻫﺬﻩ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
of this policy the sole and absolute owner of in ‫ ﻳﺠﺐ ﺍﺭﺳﺎﻝ نﺴﺨﺔ ﻣﻦ‬.‫ﺍﻟﻤﺎﻟﻚ ﺍﻟﻮﺣﻴﺪ ﻭﺍﻟﻤﻄﻠﻖ ﻟﻠﻤﺮﻛﺒﺔ‬
the vehicle. Vehicle ownership document (if not ‫ﺍﺳﺘﻤﺎﺭﺓ ﺍﻟﻤﺮﻛﺒﺔ ﻭﺍﻟﻤﺴﺘﻨﺪﺍﺕ ﺍﻟﻤﺴﺎنﺪﺓ ﺍﻟى ﺍﻟﺸﺮﻛﺔ ﻓي‬
provided) shall be provided to the company no ‫ ﺃﻳﺎﻡ ﻣﻦ ﺍﺻﺪﺍﺭ ﺍﻟﺒﻮﻟﻴﺼﺔ‬7 ‫ﻏﻀﻮﻥ‬
longer than 7 days following policy issuance
Applicable Tax es Applicable Tax es
Applicable Taxes: You accept and agree to pay ‫ﻏﻴﺮ ﻣﺤﺪﺩ‬
S pecial Conditions ‫ﺷﺮﻭط ﺧ ﺎﺻﺔ‬
any taxes on this Policy, in compliance with the
laws and regulations applicable in the territory
of sale, including but not limited to value
added tax VAT, which are due on Your Policy,
within fifteen working days from the date of
request to pay by AXA. AXA will contact you in
the event that VAT is applicable to Your Policy.
Failure by You to pay any applicable taxes may
result in Your Policy being rendered null and
void or cancelled at AXA"s discretion

S igned on behalf of the com pany ‫ﻭﻗﻌﻬ ﺎ نﻴ ﺎﺑﺔ ﻋﻦ ﺍﻟﺸﺮﻛﺔ‬

Attorney
‫ﺍﻟﻤﺨﻮﻝ ﺑ ﺎﻟﺘﻮﻗﻴﻊ‬

Com pany S eal ‫ﺧﺘﻢ ﺍﻟﺸﺮﻛﺔ‬

AXA Cooperative Insurance Company CR-No 1010271203 P.O.Box 753 Al Riyadh 11421, Kanoo Tower, King Abdul Aziz ‫ ﺍﻟﻄﺎﺑﻖ ﺍﻟﺜﺎني‬،‫ ﺷﺎﺭﻉ ﺍﻟﻤﻠﻚ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ‬،‫ ﺑﺮﺝ ﻛﺎنﻮ‬11421 ‫ ﺍﻟﺮﻳﺎﺽ‬753 ‫ ﺹ ﺏ‬1010271203 : ‫ﺷﺮﻛﺔ ﺃﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭني ﺱ ﺕ‬
Road,2nd Floor, Al Riyadh, KSA.
Telephone :8001160020 & 8001164845 8001164845 & 8001160020 : ‫ ﻫﺎﺗﻒ‬00966118140874 :‫ﻓﺎﻛﺲ‬
Fax : 00966 (11) 4780418 motorclaims.reg-ksa@axa-cooperative.com :‫ ﺍﻟﺒﺮﻳﺪ ﺍالﻟﻜﺘﺮﻭني‬www.axa-cooperative.com :‫ﺍﻹﻟﻜﺘﺮﻭني ﺍﻟﻤﻮﻗﻊ‬
Email : motorclaims.reg-ksa@axa-cooperative.com Website :www.axa-cooperative.com
A company registered with the Ministry of Commerce and Industry of the Kingdom of Saudi Arabia under Commercial ‫ ﻭﺗﺤﻤﻞ ﺭﺧﺼﺔ ﺗﺄﻣﻴﻦ ﺭﻗﻢ‬1010271203 ‫ﺷﺮﻛﺔ ﻣﺴﺠﻠﺔ ﻓي ﻭﺯﺍﺭﺓ ﺍﻟﺼﻨﺎﻋﺔ ﻭﺍﻟﺘﺠﺎﺭﺓ ﻟﻠﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﺑﺴﺠﻞ ﺗﺠﺎﺭﻱ ﺭﻗﻢ‬
Registration No. 1010271203 and holding Insurance license No. TMN/25/20101 issued by the Saudi Arabian Monetary ‫ﺻﺎﺩﺭﺓ ﻣﻦ ﻗﺒﻞ ﻣﺆﺳﺴﺔ ﺍﻟﻨﻘﺪ ﺍﻟﻌﺮﺑي ﺍﻟﺴﻌﻮﺩﻱ‬TMN/25/20101
Agency
 Principle 1: Fair dealing Principle 7: Priv acy inform ation protection
Companies must deal with consumers and beneficiaries in a fair and The Company shall protect the insurance and financial data of the

transparent way in all their relationship stages, to fulfill the obligations under consumers and not to use it except for certain and occupational

the systems, regulations and instructions of the Agency. The Company must purposes and with the consumers’ consent and

follow the best-accepted practices to fulfill the consumers’ obligations and to not disclose this information to any third party except under the prior

make it written consent of the Agency or the consumer.

an integral part of the Company’s culture, also to use its best efforts in serving the Principle 8: Proces s ing com plaints

consumers, low-income beneficiaries, old people and people with special needs of The Company shall provide a proper mechanism for consumers to submit

the two genders. their complaints, which shall be fair, clear and effective, through which

complaints could be followed up and addressed according to the regulations

Principle 2: Dis clos ure and trans parency
and instructions issued by the Agency and the relevant authorities.
The Company shall define the obligations and rights of every party, pricing details

and commissions obtained by the Company, risks, termination mechanism and the

consequences on the consumer. The Company should make sure that the insurance Principle 9: Com petition

policies, exclusions and benefits are clear, understood and accurate and accessible The Company should compete to provide the best products, services and

by the customers and can be read easily. The Company and its associates should prices with what meets the customer needs and wants and without

answer all the consumers’ questions related to the insurance products which prejudice to the regulations and instructions related to the mechanism and

it offers or related to insurance policies that it has issued. method of pricing the insurance products.
The Company should update the information of these services and products in
Principle 10: The s erv ice prov iders on behalf of the com panies
addition to providing information for insurance products and services provided by
The Company must ensure the commitment of the assigned external parties
the Company on its website.
to these principles, to work in favor of the consumers’ interest and to take

the responsibility of protecting them. The insurance services providers are

Principle 3: Ins urance culture and aw arenes s
responsible for the conducted procedures on behalf of the Company or
The Company must set a proper program and mechanism to develop the
consumers according to the assignment list issued by the Agency.
awareness and skills of current and potential consumers and beneficiaries,

to raise the level of guidance and awareness, enabling them to understand

the main risks of products, help them to make the right decisions and guide Principle 11: Conflict of interes ts
them to the right destination to obtain the needed information when The Company shall have a written policy concerning the conflict of interests
required. and to identify the necessary procedures to ensure the fair treatment with all

customers. The Company shall ensure that the policies helping in disclosing
Principle 4: Work ethics and conduct
the potential operations
The Company shall operate in a professional and responsible way in providing
of conflict of interests exist and applied. If a conflict of interests occurs
its services and performing its duties and obligations with high quality and on
between the Company and third party, and the conflict has any potential
time to the benefit of
affect on the customer, the Company shall disclose this conflict to the
the consumers and beneficiaries. The Company is the first responsible party for
consumer according to the related regulation and instructions.
protecting the customer’s insurance interests.

Principle 5: Non-dis crim ination and preference

The Company shall deal with its current and future consumers on equal basis Principle 12: S ufficient res ources
without discrimination of race, sex or otherwise. The Company shall take care to provide the required administrative,

Principle 6: Protection agains t fraud financial, operational and human resources to perform its tasks and serve
The Company shall apply the maximum level of security measures and its consumers in all the areas of the Kingdom where they are located.
procedures to control and protect the insurance

AXA Cooperative Insurance Company CR-No 1010271203 P.O.Box 753 Al Riyadh 11421, Kanoo Tower, King Abdul Aziz ‫ ﺍﻟﻄﺎﺑﻖ ﺍﻟﺜﺎني‬،‫ ﺷﺎﺭﻉ ﺍﻟﻤﻠﻚ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ‬،‫ ﺑﺮﺝ ﻛﺎنﻮ‬11421 ‫ ﺍﻟﺮﻳﺎﺽ‬753 ‫ ﺹ ﺏ‬1010271203 : ‫ﺷﺮﻛﺔ ﺃﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭني ﺱ ﺕ‬
Road,2nd Floor, Al Riyadh, KSA.
Telephone :8001160020 & 8001164845 8001164845 & 8001160020 : ‫ ﻫﺎﺗﻒ‬00966118140874 :‫ﻓﺎﻛﺲ‬
Fax : 00966 (11) 4780418 motorclaims.reg-ksa@axa-cooperative.com :‫ ﺍﻟﺒﺮﻳﺪ ﺍالﻟﻜﺘﺮﻭني‬www.axa-cooperative.com :‫ﺍﻹﻟﻜﺘﺮﻭني ﺍﻟﻤﻮﻗﻊ‬
Email : motorclaims.reg-ksa@axa-cooperative.com Website :www.axa-cooperative.com
A company registered with the Ministry of Commerce and Industry of the Kingdom of Saudi Arabia under Commercial ‫ ﻭﺗﺤﻤﻞ ﺭﺧﺼﺔ ﺗﺄﻣﻴﻦ ﺭﻗﻢ‬1010271203 ‫ﺷﺮﻛﺔ ﻣﺴﺠﻠﺔ ﻓي ﻭﺯﺍﺭﺓ ﺍﻟﺼﻨﺎﻋﺔ ﻭﺍﻟﺘﺠﺎﺭﺓ ﻟﻠﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﺑﺴﺠﻞ ﺗﺠﺎﺭﻱ ﺭﻗﻢ‬
Registration No. 1010271203 and holding Insurance license No. TMN/25/20101 issued by the Saudi Arabian Monetary ‫ﺻﺎﺩﺭﺓ ﻣﻦ ﻗﺒﻞ ﻣﺆﺳﺴﺔ ﺍﻟﻨﻘﺪ ﺍﻟﻌﺮﺑي ﺍﻟﺴﻌﻮﺩﻱ‬TMN/25/20101
Agency
AXA Cooperative Insurance Company CR-No 1010271203 P.O.Box 753 Al Riyadh 11421, Kanoo Tower, King Abdul Aziz ‫ ﺍﻟﻄﺎﺑﻖ ﺍﻟﺜﺎني‬،‫ ﺷﺎﺭﻉ ﺍﻟﻤﻠﻚ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ‬،‫ ﺑﺮﺝ ﻛﺎنﻮ‬11421 ‫ ﺍﻟﺮﻳﺎﺽ‬753 ‫ ﺹ ﺏ‬1010271203 : ‫ﺷﺮﻛﺔ ﺃﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭني ﺱ ﺕ‬
Road,2nd Floor, Al Riyadh, KSA.
Telephone :8001160020 & 8001164845 8001164845 & 8001160020 : ‫ ﻫﺎﺗﻒ‬00966118140874 :‫ﻓﺎﻛﺲ‬
Fax : 00966 (11) 4780418 motorclaims.reg-ksa@axa-cooperative.com :‫ ﺍﻟﺒﺮﻳﺪ ﺍالﻟﻜﺘﺮﻭني‬www.axa-cooperative.com :‫ﺍﻹﻟﻜﺘﺮﻭني ﺍﻟﻤﻮﻗﻊ‬
Email : motorclaims.reg-ksa@axa-cooperative.com Website :www.axa-cooperative.com
A company registered with the Ministry of Commerce and Industry of the Kingdom of Saudi Arabia under Commercial ‫ ﻭﺗﺤﻤﻞ ﺭﺧﺼﺔ ﺗﺄﻣﻴﻦ ﺭﻗﻢ‬1010271203 ‫ﺷﺮﻛﺔ ﻣﺴﺠﻠﺔ ﻓي ﻭﺯﺍﺭﺓ ﺍﻟﺼﻨﺎﻋﺔ ﻭﺍﻟﺘﺠﺎﺭﺓ ﻟﻠﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﺑﺴﺠﻞ ﺗﺠﺎﺭﻱ ﺭﻗﻢ‬
Registration No. 1010271203 and holding Insurance license No. TMN/25/20101 issued by the Saudi Arabian Monetary ‫ﺻﺎﺩﺭﺓ ﻣﻦ ﻗﺒﻞ ﻣﺆﺳﺴﺔ ﺍﻟﻨﻘﺪ ﺍﻟﻌﺮﺑي ﺍﻟﺴﻌﻮﺩﻱ‬TMN/25/20101
Agency