Private Car Comprehensive Insurance ‫ﻃﻠﺐ اﻟﺘﺄﻣﻴﻦ اﻟﺸﺎﻣﻞ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬

POLICYHOLDER DETAILS ‫اﻟﻤﺆﻣﻦ ﻟﻪ‬

‫ﱠ‬ ‫ﺑﻴﺎﻧﺎت‬

Insured Name: :‫اﻟﻤﺆﻣﻦ ﻟﻪ‬

‫ﱠ‬ ‫اﺳﻢ‬
Insured ID /Iqama/CR.No.: :‫اﻟﻤﺆﻣﻦ ﻟﻪ‬
‫ﱠ‬ ‫رﻗﻢ ﻫﻮﻳﺔ‬
Education: :‫اﻟﻤﺴﺘﻮى اﻟﺘﻌﻠﻴﻤﻲ‬
Marital Status: :‫اﻟﺤﺎﻟﺔ اﺟﺘﻤﺎﻋﻴﺔ‬
Number of Children under Age 16 years: :‫ ﻋﺎم‬١٦ ‫ﻋﺪد ا­ﻃﻔﺎل دون ﻋﻤﺮ‬
Occupation: :‫اﻟﻤﻬﻨﺔ‬
Insured date of birth: :‫اﻟﻤﺆﻣﻦ ﻟﻪ‬
‫ﱠ‬ ‫ﺗﺎرﻳﺦ ﻣﻴﻼد‬
Tel(Direct): Ext: :‫ﺗﺤﻮﻳﻠﺔ‬ :(‫ﻫﺎﺗﻒ )ﻣﺒﺎﺷﺮ‬
Mobile: :‫ﺟﻮال‬
Office/Business Address: :‫اﻟﺸﺮﻛﺔ‬/‫ﻋﻨﻮان اﻟﻤﻜﺘﺐ‬
Tel(Office): Fax No.: :‫رﻗﻢ اﻟﻔﺎﻛﺲ‬ :(‫ﻫﺎﺗﻒ )ﻣﻜﺘﺐ‬
Mileage expected to be driven per year: :‫ﻋﺪد ا­ﻣﻴﺎل اﻟﻤﺘﻮﻗﻊ ﻗﻄﻌﻬﺎ ﻛﻞ ﺳﻨﺔ‬
Email: :‫اﻟﺒﺮﻳﺪ اﻟﻜﺘﺮوﻧﻲ‬
Period of insurance: (Gregorian Year Required) From: To: :‫إﻟﻰ‬ :‫ﻣﻦ‬ (‫)ﺑﺎﻟﺴﻨﺔ اﻟﻤﻴﻼدﻳﺔ‬ :‫ﻣﺪة اﻟﺘﺄﻣﻴﻦ‬

National Address ‫اﻟﻌﻨﻮان اﻟﻮﻃﻨﻲ‬

* Building No. ‫@ رﻗﻢ اﻟﻤﺒﻨﻰ‬

* City ‫@ اﻟﻤﺪﻳﻨﺔ‬
* District ‫@ اﻟﺤﻲ‬
* Street ‫@ اﻟﺸﺎرع‬
* Postal Code ‫@ اﻟﺮﻣﺰ اﻟﺒﺮﻳﺪي‬
* Additional Code ‫@ اﻟﺮﻣﺰ اﻻﺿﺎﻓﻲ‬
* Mandatory Fields ‫@ ﺣﻘﻮل إﻟﺰاﻣﻴﺔ‬

DRIVER DETAILS ‫ﻣﻌﻠﻮﻣﺎت اﻟﺴﺎﺋﻖ‬

Age: :‫اﻟﻌﻤﺮ‬
ُ
Gender: :‫اﻟﺠﻨﺲ‬
Education: :‫اﻟﻤﺴﺘﻮى اﻟﺘﻌﻠﻴﻤﻲ‬
Marital Status: :‫اﻟﺤﺎﻟﺔ اﺟﺘﻤﺎﻋﻴﺔ‬
No. of Children under age 16 yeas: :‫ ﺳﻨﺔ‬١٦ ‫ﻋﺪد ا­ﻃﻔﺎل دون ﻋﻤﺮ‬
Occupation: :‫اﻟﻤﻬﻨﺔ‬
Residential Address: :‫ﻋﻨﻮان اﻟﺴﻜﻦ‬
Office/Business Address: :‫اﻟﺸﺮﻛﺔ‬/‫ﻋﻨﻮان اﻟﻤﻜﺘﺐ‬
Type of Driving License: :‫ﻧﻮع رﺧﺼﺔ اﻟﻘﻴﺎدة‬
No. of years Saudi license held for: :‫ﻋﺪد ﺳﻨﻮات إﻣﺘﻼك اﻟﺮﺧﺼﺔ اﻟﺴﻌﻮدﻳﺔ‬
Names of other countries for which a valid driving license is currently being held: :‫أﺳﻤﺎء اﻟﺪول ا­ﺧﺮى اﻟﺘﻲ ﺗﺤﻤﻞ ﻣﻨﻬﺎ رﺧﺼﺔ ﻗﻴﺎدة ﺳﺎرﻳﺔ اﻟﻤﻔﻌﻮل‬

Number of years for which driving license has been held for each country :‫ﻋﺪد ﺳﻨﻮات إﻣﺘﻼك رﺧﺼﺔ اﻟﻘﻴﺎدة ﻟﻜﻞ دوﻟﺔ ﻣﻦ اﻟﺪول اﻟﻤﺬﻛﻮرة أﻋﻼه‬
mentioned above:

Years’ eligible for No Claims Discount: :‫ﻋﺪد اﻟﺴﻨﻮات اﻟﻤﺆﻫﻠﺔ ﻟﻠﺤﺼﻮل ﻋﻠﻰ ﺧﺼﻢ ﻋﺪم وﺟﻮد ﻣﻄﺎﻟﺒﺎت‬
Number of at-fault accidents in the last 5 years: :‫اﻟﻤﺆﻣﻦ ﻟﻪ ﻓﻲ ا­ﻋﻮام اﻟﺨﻤﺴﺔ اﻟﻤﺎﺿﻴﺔ‬
‫ﱠ‬ ‫ﻋﺪد اﻟﺤﻮادث اﻟﺘﻲ ﻳﻘﻊ ﻓﻴﻬﺎ اﻟﺨﻄﺄ ﻋﻠﻰ‬
Number of at-fault Claims in the last 5 years: :‫اﻟﻤﺆﻣﻦ ﻟﻪ ﻓﻲ ا­ﻋﻮام اﻟﺨﻤﺴﺔ اﻟﻤﺎﺿﻴﺔ‬
‫ﱠ‬ ‫ﻋﺪد اﻟﻤﻄﺎﻟﺒﺎت اﻟﺘﻲ ﻳﻘﻊ ﻓﻴﻬﺎ اﻟﺨﻄﺄ ﻋﻠﻰ‬
Road Convictions e.g. High speeding fines, traffic light violations etc: :(‫ ﻗﻄﻊ اﺷﺎرات اﻟﻤﺮورﻳﺔ وﺧﻼﻓﻬﺎ‬،‫اﻟﻤﺨﺎﻟﻔﺎت اﻟﻤﺮورﻳﺔ )ﻏﺮاﻣﺔ ﺗﺠﺎوز اﻟﺴﺮﻋﺔ‬
Medical Conditions as stated in the driving license: :‫اﻟﻈﺮوف واﻟﻘﻴﻮد اﻟﺼﺤﻴﺔ ﻛﻤﺎ ﻫﻮ وارد ﻓﻲ رﺧﺼﺔ اﻟﻘﻴﺎدة‬

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‫‪Private Car Comprehensive Insurance‬‬ ‫ﻃﻠﺐ اﻟﺘﺄﻣﻴﻦ اﻟﺸﺎﻣﻞ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬
‫‪VEHICLE(S) TO BE INSURED (PLEASE ATTACH A COPY OF‬‬ ‫)‪THE VEHICLE REGISTRATION‬‬ ‫)اﻟﺮﺟﺎء إرﻓﺎق ﻧﺴﺨﺔ ﻣﻦ اﻻﺳﺘﻤﺎرة(‬ ‫ﺑﻴﺎن اﻟﻤﺮﻛﺒﺔ‪ /‬اﻟﻤﺮﻛﺒﺎت اﻟﻤﻄﻠﻮب اﻟﺘﺄﻣﻴﻦ ﻋﻠﻴﻬﺎ‬

‫رﻗﻢ اﻟﻬﻴﻜﻞ‬ ‫ﺳﻨﺔ اﻟﺼﻨﻊ‬ ‫ﺑﻠﺪ اﻟﺸﺮﻛﺔ اﻟﻤﺼﻨﻌﺔ ﻟﻠﻤﺮﻛﺒﺔ‬ ‫رﻗﻢ اﻟﻠﻮﺣﺔ‬
‫‪Chassis No.‬‬ ‫‪Manufacturing Year‬‬ ‫‪Nationality of Vehicle‬‬ ‫‪Plate No.‬‬
‫‪Manufacturer‬‬

‫رﻗﻢ اﻟﺒﻄﺎﻗﺔ اﻟﺠﻤﺮﻛﻴﺔ ‪ /‬اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬ ‫ﺗﺎرﻳﺦ إﻧﺘﻬﺎء رﺧﺼﺔ اﻟﺴﻴﺮ‬ ‫ﻟﻮن اﻟﻤﺮﻛﺒﺔ‬ ‫اﻟﻘﻴﻤﺔ اﻟﻤﻘﺪرة ﻟﻠﻤﺮﻛﺒﺔ‬
‫‪Custom Card No. / Sequence No.‬‬ ‫‪Vehicle Registration‬‬ ‫‪Vehicle Color‬‬ ‫‪Estimated Vehicle Value‬‬
‫‪Expiry Date‬‬

‫اﻟﺴﻌﺔ ارﻛﺎﺑﻴﺔ‬ ‫اﻟﻤﻮدﻳﻞ‬ ‫ﻧﻮع اﻟﻤﺮﻛﺒﺔ‬ ‫ﺟﺴﻢ اﻟﻤﺮﻛﺒﺔ‬

‫‪Seating Capacity‬‬ ‫‪Model‬‬ ‫‪Make‬‬ ‫‪Body Type‬‬

‫ﻗﻴﻤﺔ اﻟﻤﻠﺤﻘﺎت‬ ‫اﻟﻤﺴﺎﻓﺔ اﻟﻤﻘﻄﻮﻋﺔ ﺣﺎﻟﻴ‪Ê‬‬ ‫)ﺳﻨﺘﻴﻤﺘﺮ ﻣﻜﻌﺐ أو ﺑﺎﻟﻠﺘﺮ(‬ ‫ﺣﺠﻢ اﻟﻤﺤﺮك‬
‫‪Additional Accessories‬‬ ‫‪Current Mileage‬‬ ‫)‪Engine Size (CC or litres‬‬

‫‪ADDITIONAL INFORMATION OF THE VEHICLE TO BE INSURED‬‬ ‫ﻣﻌﻠﻮﻣﺎت إﺿﺎﻓﻴﺔ ﻋﻦ اﻟﻤﺮﻛﺒﺔ‬

‫‪Transmission (Manual/Automatic):‬‬ ‫ﻧﺎﻗﻞ اﻟﺤﺮﻛﺔ )ﻳﺪوي‪/‬أوﺗﻮﻣﺎﺗﻴﻜﻲ(‪:‬‬

‫‪Location where vehicle is kept overnight (road-side, drive-way, garage):‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻣﻜﺎن إﻳﻘﺎف اﻟﻤﺮﻛﺒﺔ أﺛﻨﺎء اﻟﻠﻴﻞ )اﻟﺸﺎرع‪ ،‬اﻟﻤﻤﺮ اﻟﻤﺆدي ﻟﻠﻤﻨﺰل‪ ،‬اﻟﻤﺮآب(‪:‬‬
‫‪Anti-theft alarm (in working order):‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺟﻬﺎز إﻧﺬار ﺿﺪ اﻟﺴﺮﻗﺔ )ﻓﻲ ﺣﺎﻟﺔ ﻋﻤﻞ ﺟ ﱢﻴﺪة(‪:‬‬
‫‪Anti-lock braking system:‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻧﻈﺎم ﻣﻜﺎﺑﺢ ﻣﺎﻧﻊ ﻟ½ﻧﺰﻻق؟‬
‫‪Automatic braking system (to prevent or reduce impact of imminent collision):‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻧﻈﺎم ﻣﻜﺎﺑﺢ أوﺗﻮﻣﺎﺗﻴﻜﻲ ) ﻟﻤﻨﻊ وﻗﻮع اﺻﻄﺪام اﻟﻮﺷﻴﻚ أو اﻟﺤﺪ ﻣﻦ آﺛﺎره(‪ :‬ﻧﻌﻢ‬
‫?‪Cruise Control‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺟﻬﺎز ﻣﺜ ﱢﺒﺖ اﻟﺴﺮﻋﺔ؟‬
‫?‪Adaptive Cruise control‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫اﻟﺘﻜﻴﻔﻲ )اﻟﻔﻌﱠ ﺎل(؟‬
‫‪Ã‬‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺟﻬﺎز ﻣﺜ ﱢﺒﺖ اﻟﺴﺮﻋﺔ‬
‫?‪Rear parking sensors‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ اﻟﺤﺴﺎﺳﺎت اﻟﺨﻠﻔﻴﺔ ﻟﻠﻤﻮاﻗﻒ؟‬
‫?‪Front Sensors‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺣﺴﺎﺳﺎت أﻣﺎﻣﻴﺔ؟‬
‫?‪Front Camera‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻛﺎﻣﻴﺮا أﻣﺎﻣﻴﺔ؟‬
‫?‪Rear Camera‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻛﺎﻣﻴﺮا ﺧﻠﻔﻴﺔ؟‬
‫?‪360-degree Camera‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻛﺎﻣﻴﺮا ذات اﻟـ ‪ ٣٦٠‬درﺟﺔ؟‬
‫‪Fire extinguisher (Commercial vehicles only):‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻃﻔﺎﻳﺔ ﺣﺮﻳﻖ )ﻟﻠﻤﺮﻛﺒﺎت اﻟﺘﺠﺎرﻳﺔ ﻓﻘﻂ(؟‬
‫‪Modification in the car? (details):‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ أي ﺗﻌﺪﻳﻼت؟ )ذﻛﺮ اﻟﺘﻔﺎﺻﻴﻞ(‪:‬‬
‫‪Vehicle Axle Weight (from commercial vehicles only):‬‬ ‫وزن ﻣﺤﺎور اﻟﻌﺠﻼت )ﻟﻠﻤﺮﻛﺒﺎت اﻟﺘﺠﺎرﻳﺔ ﻓﻘﻂ(؟‬

‫‪OPTIONAL BENEFITS & EXTENSIONS OF COVER‬‬ ‫اﻟﻤﻨﺎﻓﻊ واﻟﺘﻐﻄﻴﺎت اˆﺿﺎﻓﻴﺔ اˆﺧﺘﻴﺎرﻳﺔ‬

‫‪Personal Accident to driver only:‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫اﻟﺤﻮادث اﻟﺸﺨﺼﻴﺔ ﻟﻠﺴﺎﺋﻖ‪:‬‬
‫‪Personal Accident to drivers & Passengers:‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫اﻟﺤﻮادث اﻟﺸﺨﺼﻴﺔ ﻟﻠﺴﺎﺋﻖ واﻟﺮﻛﺎب‪:‬‬
‫‪Agency/Dealer Repair:‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫اﺻﻼح ﻟﺪى اﻟﻮﻛﺎﻟﺔ‪:‬‬

‫‪Geographical Extensions‬‬ ‫ﺗﻮﺳﻌﺔ اﻟﺤﺪود اﻟﺠﻐﺮاﻓﻴﺔ‬

‫‪Kingdom of Bahrain:‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻣﻤﻠﻜﺔ اﻟﺒﺤﺮﻳﻦ‪:‬‬
‫‪GCC Countries:‬‬ ‫‪No‬‬ ‫‪ Yes‬ﻻ‬ ‫ﻧﻌﻢ‬ ‫دول ﻣﺠﻠﺲ اﻟﺘﻌﺎون اﻟﺨﻠﻴﺠﻲ‪:‬‬

‫‪Deductible Required:‬‬ ‫اﻟﺘﺤﻤﻞ اﻟﻤﻄﻠﻮب‪:‬‬

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 Private Car Comprehensive Insurance ‫ﻃﻠﺐ اﻟﺘﺄﻣﻴﻦ اﻟﺸﺎﻣﻞ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬
GENERAL INFORMATION ‫ﻣﻌﻠﻮﻣﺎت ﻋﺎﻣﺔ‬
Usage ‫اﻻﺳﺘﻌﻤﺎل‬

Social / Domestic / entertainment/ driving from to work No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ اﻟﻘﻴﺎدة ﻣﻦ وإﻟﻰ اﻟﻌﻤﻞ‬/‫ ﺗﺮﻓﻴﻪ‬/‫ ﺧﺎص‬/‫اﺟﺘﻤﺎﻋﻲ‬
No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ﺳﺎﺋﻖ ﺧﺎص‬
Domestic driver
Public Hire (Taxi, Rental, Long term Lease) Uber or ‫ ﺗﺄﺟﻴﺮ ﻣﺪة ﻃﻮﻳﻠﺔ( أوﺷﺮﻛﺔ‬،‫ ﺗﺄﺟﻴﺮ ﻳﻮﻣﻲ‬،‫ ﺗﺄﺟﻴﺮ ﺧﺎص‬،‫ﺗﺄﺟﻴﺮ ﻋﺎم )ﺳﻴﺎرات أﺟﺮة‬

similar use No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫أوﺑﺮ أو إﺳﺘﺨﺪام ﻣﻤﺎﺛﻞ‬

Commercial Use No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫إﺳﺘﺨﺪام ﺗﺠﺎري‬

Hypothecation (Financial Ownership interest, if any) No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬ ‫ﻣﺴﺘﻔﻴﺪ آﺧﺮ أو أي ﺷﺨﺺ ﻟﻪ ﻣﺼﻠﺤﺔ ﻣﺎﻟﻴﺔ إن وﺟﺪ‬

Will any one below age 18 years drive the vehicle? ‫ ﺳﻨﺔ؟‬١٨ ‫ﻫﻞ ﺳﻴﻘﻮد اﻟﻤﺮﻛﺒﺔ أي ﺳﺎﺋﻖ ﻋﻤﺮه دون‬
If yes , please give & names & Date of birth & License No. No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬ .‫إذا ﻛﺎﻧﺖ اﺟﺎﺑﺔ ﺑﻨﻌﻢ ﻳﺮﺟﻰ إﻋﻄﺎء ا­ﺳﻤﺎء وﺗﺎرﻳﺦ اﻟﻤﻴﻼد وأرﻗﺎم رﺧﺺ اﻟﻘﻴﺎدة‬

Were you qualified for the discount of not having any claim in ‫ﻫﻞ ﻛﻨﺖ ﺗﺴﺘﺤﻖ ﺧﺼﻢ ﻋﺪم وﺟﻮد ﻣﻄﺎﻟﺒﺎت ﻓﻲ ﺷﺮﻛﺎت‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
previous insurance companies? ‫اﻟﺘﺄﻣﻴﻦ اﻟﺴﺎﺑﻘﺔ؟‬

Number of years that has not occurred any claim ‫ﻋﺪد اﻟﺴﻨﻮات اﻟﺘﻲ ﻟﻢ ﻳﺤﺪث ﻓﻴﻬﺎ أي ﻣﻄﺎﻟﺒﺔ‬
(Attach Evidence In Original) (‫)إرﻓﺎق أﺻﻞ اﻻﺛﺒﺎت‬

Do you have other cars insured with the company? No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬ ‫ﻫﻞ ﻟﺪﻳﻚ ﺳﻴﺎرات أﺧﺮى ﻣﺆﻣﻨﺔ ﻟﺪى اﻟﺸﺮﻛﺔ؟‬
If The Answer is yes, please Provide details of the vehicle?
(‫)ﻓﻲ ﺣﺎل اﺟﺎﺑﺔ ﺑﻨﻌﻢ ﻳﺮﺟﻰ ﺗﻘﺪﻳﻢ ﺗﻔﺎﺻﻴﻞ ﻋﻦ اﻟﻤﺮﻛﺒﺔ‬

Are any Those who drive the car suffers From Physical disability? No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬ ‫ﻫﻞ أي ﻣﻤﻦ ﻳﻘﻮدون اﻟﺴﻴﺎرة ﻳﻌﺎﻧﻲ ﻣﻦ إﻋﺎﻗﺔ ﺟﺴﺪﻳﺔ؟‬

Are you involved in any Traffic offence ? No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬ ‫ﻫﻞ ﺳﺒﻖ وأن ﺗﻌﺮﺿﺘﻢ ­ي ﻣﺨﺎﻟﻔﺎت ﻣﺮورﻳﺔ؟‬

Are you are involved in any traffic accident during the past three ‫ ﻓﻲ أي ﺣﺎدث ﻣﺮوري ﺧﻼل ا­ﻋﻮام اﻟﺜﻼث‬Ê‫ﻫﻞ ﻛﻨﺖ ﻃﺮﻓ‬
years? No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬ ‫اﻟﻤﺎﺿﻴﺔ؟‬

TELEMATICS DATA ‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﺨﺎﺻﺔ ﺑﺎﻟﺘﻠﻴﻤﺎﺗﻴﺔ‬

Driver’s score in respect of the following: :‫اﻟﺪرﺟﺎت اﻟﺘﻲ ﺣﺼﻞ ﻋﻠﻴﻬﺎ اﻟﺴﺎﺋﻖ ﻓﻲ ﻛﻞ ﻣﻤﺎ ﻳﻠﻲ‬
(1) Use of braking: :‫( إﺳﺘﺨﺪام اﻟﻤﻜﺎﺑﺢ‬١)

(2) Acceleration: :‫( اﻟﺘﺴﺎرع‬٢)

(3) Cornering: :‫( ﺗﺠﺎوز اﻟﻤﻨﻌﻄﻔﺎت‬٣)

(4) Adherence to speed limit: :‫( اﻟﺘﺰام ﺑﺎﻟﺴﺮﻋﺔ اﻟﻤﺤﺪدة‬٤)

(5) Time of the day: :‫( اﻟﻮﻗﺖ‬٥)

(6) Mileage: :‫( اﻟﻤﺴﺎﻓﺔ اﻟﻤﻘﻄﻮﻋﺔ‬٦)

(7) Use of Seat-belts: :‫( إﺳﺘﺨﺪام أﺣﺰﻣﺔ ا­ﻣﺎن‬٧)

PAST YEARS LOSSES/CLAIMS ‫اﻟﻤﻄﺎﻟﺒﺎت ﺧﻼل اﻟﺴﻨﻮات اﻟﻤﺎﺿﻴﺔ‬/‫ﺗﻔﺎﺻﻴﻞ اﻟﺨﺴﺎﺋﺮ‬

‫ﻣﻼﺣﻈﺎت‬ ‫إﺟﻤﺎﻟﻲ اﻟﻤﺒﻠﻎ اﻟﻤﺪﻓﻮع‬ ‫اﺻﺎﺑﺎت ﻟﻠﻄﺮف اﻟﺜﺎﻟﺚ‬ ‫أﺿﺮار اﻟﻄﺮف اﻟﺜﺎﻟﺚ‬ ‫ا­ﺿﺮار‬ ‫ﺗﺎرﻳﺦ اﻟﺤﺎدث‬
Notes Grand Total Injury to third Party Damages to TP Damages Date of accident

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Private Car Comprehensive Insurance ‫ﻃﻠﺐ اﻟﺘﺄﻣﻴﻦ اﻟﺸﺎﻣﻞ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬
NUMBER OF BANK ACCOUNT ‫رﻗﻢ اﻟﺤﺴﺎب اﻟﺒﻨﻜﻲ‬
The Bank that you are dealing with ‫إﺳﻢ اﻟﺒﻨﻚ اﻟﺬي ﺗﺘﻌﺎﻣﻞ ﻣﻌﻪ‬

IBAN No. SA (‫رﻗﻢ اﻟﺤﺴﺎب )أي ﺑﺎن‬

DECLARATION AND ACCEPTANCE ‫إﻗﺮار وﻗﺒﻮل‬

I/We the undersigned and in compliance with the Rules on the Collection and ‫ﻧﺤﻦ‬/‫ أواﻓﻖ أﻧﺎ‬،‫ ﺑﻘﻮاﻋﺪ ﺟﻤﻊ و ﺗﺒﺎدل اﻟﻤﻌﻠﻮﻣﺎت اﻟﺘﺄﻣﻴﻨﻴﺔ ﻟﻠﻤﺮﻛﺒﺎت‬Ê‫إﻟﺘﺰاﻣ‬
Exchange of Motor Insurance Information; hereby agree to grant Aljazira ‫اﻟﻤﻮ ﱢﻗﻌﻴﻦ أدﻧﺎه ﻋﻠﻰ ﻣﻨﺢ ﺷﺮﻛﺔ اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ ﺗﻌﺎوﻧﻲ اﻟﺤﻖ ﻓﻲ اﻓﺼﺎح‬/‫اﻟﻤﻮ ﱢﻗﻊ‬
Takaful Ta’awuni the right to disclose, inquire and exchange my insurance ‫واﺳﺘﻌﻼم وﺗﺒﺎدل اﻟﻤﻌﻠﻮﻣﺎت اﻟﺘﺄﻣﻴﻨﻴﺔ اﻟﺨﺎﺻﺔ ﺑﻲ ﻣﻊ ﺷﺮﻛﺔ ﻧﺠﻢ ﻟﺨﺪﻣﺎت‬
information with Najm for Insurance Services Company, and agree to grant ‫ ﻛﻤﺎ أواﻓﻖ ﻋﻠﻰ ﻣﻨﺢ ﺷﺮﻛﺔ ﻧﺠﻢ ﻟﺨﺪﻣﺎت اﻟﺘﺄﻣﻴﻦ اﻟﺤﻖ ﻓﻲ اﻓﺼﺎح‬،‫اﻟﺘﺄﻣﻴﻦ‬
Najm for Insurance Services Company the right to disclose, inquire and .‫واﺳﺘﻌﻼم وﺗﺒﺎدل اﻟﻤﻌﻠﻮﻣﺎت اﻟﺘﺄﻣﻴﻨﻴﺔ اﻟﺨﺎﺻﺔ ﺑﻲ ﻣﻊ اﻟﺠﻬﺎت اﻟﻤﺼ ﱠﺮح ﻟﻬﺎ ﺑﺬﻟﻚ‬
exchange my insurance information with the authorized parties.

I/We the Hereby, undersigned (Agent/Authorized person (on behalf of the ‫أو ﺷﺨﺺ ﻣﻔﻮض ﺑﺎﻟﻨﻴﺎﺑﺔ ﻋﻦ‬/‫اﻟﻤﻮﻗﻌﻴﻦ أدﻧﺎه )وﻛﻴﻞ‬/‫ﻧﺤﻦ اﻟﻤﻮﻗﻊ‬/‫ﺑﻬﺬا أﻧﺎ‬
establishment/Company) agree to provide Aljazira Takaful Ta’awuni ‫اﻟﻤﺆﺳﺴﺔ( أواﻓﻖ ﻋﻠﻰ ﺗﺰوﻳﺪ ﺷﺮﻛﺔ اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ ﺗﻌﺎوﻧﻲ ﺑﺄي ﻣﻌﻠﻮﻣﺎت‬/‫اﻟﺸﺮﻛﺔ‬
company with any information that it requires for issuing an insurance policy ‫أو ﻟﻠﻤﺮاﺟﻌﺔ و دارة‬/‫أو ﺑﻴﺎﻧﺎت ﺗﻄﻠﺒﻬﺎ ﻣﻨﻲ ﺻﺪار ﺑﻮﻟﻴﺼﺔ اﻟﺘﺄﻣﻴﻦ ﻟﺪى اﻟﺸﺮﻛﺔ و‬
and/or auditing and/or administering my accounts and facilities therewith. .‫ﺣﺴﺎﺑﺎﺗﻲ ﻟﺪى اﻟﺸﺮﻛﺔ‬

I/We authorize it to obtain, collect, disclose and share any information as it ‫ اﻓﺼﺎح ﻋﻦ و ﻣﺸﺎرﻛﺔ أي‬،‫ ﺟﻤﻊ‬،‫ﻧﻔﻮض اﻟﺸﺮﻛﺔ ﺑﺎﻟﺤﺼﻮل ﻋﻠﻰ‬/‫ض‬
‫ﱢ‬ ‫أﻓﻮ‬
‫ﱢ‬ ‫ﻛﻤﺎ‬
deems necessary or in need for issuing an insurance policy of all types (active ‫ﻣﻌﻠﻮﻣﺎت ﺗﺮاﻫﺎ ﺿﺮورﻳﺔ أو ﺗﺤﺘﺎﺟﻬﺎ ﺻﺪار وﺛﻴﻘﺔ اﻟﺘﺄﻣﻴﻦ ﺑﺠﻤﻴﻊ أﻧﻮاﻋﻬﺎ )ﺳﻮاء‬
and expired) and/or any other financial obligation from/to the Saudi Credit ‫إﻟﻰ اﻟﺸﺮﻛﺔ اﻟﺴﻌﻮدﻳﺔ‬/‫أو أي إﻟﺘﺰام ﻣﺎﻟﻲ آﺧﺮ ﻣﻦ‬/‫ﻓﻌﺎﻟﺔ أو ﻣﻨﺘﻬﻴﺔ( و‬
‫ﻛﺎﻧﺖ ﱠ‬
Bureau (SIMAH) through the membership agreement signed with the ‫ﱠ‬
.‫اﻟﻤﻮﻗﻌﺔ ﻣﻊ اﻟﺸﺮﻛﺔ‬ ‫ﻟﻠﻤﻌﻠﻮﻣﺎت اﺋﺘﻤﺎﻧﻴﺔ )ﺳﻤﺔ( وذﻟﻚ ﻣﻦ ﺧﻼل إﺗﻔﺎﻗﻴﺔ اﻟﻌﻀﻮﻳﺔ‬
company.

I /we , hereby declare/agree ‫ أواﻓﻖ‬/‫ ﻧﺤﻦ اﻟﻤﻮﻗﻌﻴﻦ أدﻧﺎه أﻗﺮ‬/‫أﻧﺎ‬

A) That the information and the details disclosed in the proposal Are: :‫أ( ﺑﺄن اﻟﺒﻴﺎﻧﺎت واﻟﻤﻌﻠﻮﻣﺎت واﻟﺘﻔﺎﺻﻴﻞ اﻟﻮاردة ﻓﻲ ﻃﻠﺐ اﻟﺘﺄﻣﻴﻦ‬
1. Correct to the best of my/our knowledge. .‫ ﻛﺎﻣﻠﺔ وﺻﺤﻴﺤﺔ ﺣﺴﺐ ﻋﻠﻤﻲ واﻋﺘﻘﺎدي‬.١
2. Will form the basis of the contract with the company. .‫ ﺗﻤﺜﻞ أﺳﺎس اﻟﻌﻘﺪ اﻟﻤﺒﺮم ﻣﻊ اﻟﺸﺮﻛﺔ‬.٢
B) To the terms, exclusions and conditions of the policy which I/we have read. ‫ ﻗﺮأﻧﺎﻫﺎ ﺑﻌﻨﺎﻳﺔ‬/‫ب( ﻋﻠﻰ ﺷﺮوط وأﺣﻜﺎم واﺳﺘﺜﻨﺎءات وﺛﻴﻘﺔ اﻟﺘﺄﻣﻴﻦ واﻟﺘﻲ ﻗﺮأﺗﻬﺎ‬
.‫ﻛﺎﻣﻠﺔ‬

Date ‫اﻟﺘﺎرﻳﺦ‬ Driver Name ‫إﺳﻢ اﻟﺴﺎﺋﻖ‬ Name of the applicant ‫اﺳﻢ ﻣﻘﺪم اﻟﻄﻠﺐ‬

Signature ‫اﻟﺘﻮﻗﻴﻊ‬ Signature ‫اﻟﺘﻮﻗﻴﻊ‬

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