Private Car Third Party Liability Only ‫ﻃﻠﺐ ﺗﺄﻣﻴﻦ اﻟﻤﺴﺌﻮﻟﻴﺔ ﺿﺪ اﻟﻐﻴﺮ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬

POLICYHOLDER DETAILS ‫اﻟﻤﺆﻣﻦ ﻟﻪ‬

‫ﱠ‬ ‫ﺑﻴﺎﻧﺎت‬

Insured Name: :‫اﻟﻤﺆﻣﻦ ﻟﻪ‬

‫ﱠ‬ ‫اﺳﻢ‬
Insured ID /Iqama/CR.No.: :‫اﻟﻤﺆﻣﻦ ﻟﻪ‬
‫ﱠ‬ (‫ ﺳﺠﻞ ﺗﺠﺎري‬- ‫ إﻗﺎﻣﺔ‬- ‫رﻗﻢ )ﻫﻮﻳﺔ‬
Education: :‫اﻟﻤﺴﺘﻮى اﻟﺘﻌﻠﻴﻤﻲ‬
Marital Status: :‫اﻟﺤﺎﻟﺔ ا ﺟﺘﻤﺎﻋﻴﺔ‬
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
Email: :‫اﻟﺒﺮﻳﺪ ا ﻟﻜﺘﺮوﻧﻲ‬
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 ا ﺟﺘﻤﺎﻋﻴﺔ‬
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 ا ﺷﺎرات اﻟﻤﺮورﻳﺔ وﺧﻼﻓﻬﺎ‬،‫اﻟﻤﺨﺎﻟﻔﺎت اﻟﻤﺮورﻳﺔ )ﻏﺮاﻣﺔ ﺗﺠﺎوز اﻟﺴﺮﻋﺔ‬
Medical Conditions as stated in the driving license: :‫اﻟﻈﺮوف واﻟﻘﻴﻮد اﻟﺼﺤﻴﺔ ﻛﻤﺎ ﻫﻮ وارد ﻓﻲ رﺧﺼﺔ اﻟﻘﻴﺎدة‬

4-1
‫‪Private Car Third Party Liability Only‬‬ ‫ﻃﻠﺐ ﺗﺄﻣﻴﻦ اﻟﻤﺴﺌﻮﻟﻴﺔ ﺿﺪ اﻟﻐﻴﺮ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬

‫‪Type of Cover‬‬ ‫اﻟﻄﺮف اﻟﺜﺎﻟﺚ ﺑﺎ ﺿﺎﻓﺔ‬ ‫ﻧﻮع اﻟﺘﻐﻄﻴﺔ‬

‫‪Third Party Fire & Theft‬‬ ‫‪Third Party‬‬ ‫ﻃﺮف ﺛﺎﻟﺚ‬
‫‪Required‬‬ ‫ﻟﻠﺤﺮﻳﻖ واﻟﺴﺮﻗﺔ‬ ‫اﻟﻤﻄﻠﻮﺑﺔ‬

‫‪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 ا رﻛﺎﺑﻴﺔ‬ ‫اﻟﻤﻮدﻳﻞ‬ ‫ﻧﻮع اﻟﻤﺮﻛﺒﺔ‬ ‫ﺟﺴﻢ اﻟﻤﺮﻛﺒﺔ‬

‫‪Seating Capacity‬‬ ‫‪Model‬‬ ‫‪Make‬‬ ‫‪Body Type‬‬

‫ﻗﻴﻤﺔ اﻟﻤﻠﺤﻘﺎت‬ ‫اﻟﻤﺴﺎﻓﺔ اﻟﻤﻘﻄﻮﻋﺔ ﺣﺎﻟﻴ‪Í‬‬ ‫)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):‬‬ ‫ﻣﻜﺎن إﻳﻘﺎف اﻟﻤﺮﻛﺒﺔ أﺛﻨﺎء اﻟﻠﻴﻞ )اﻟﺸﺎرع‪ ،‬اﻟﻤﻤﺮ اﻟﻤﺆدي ﻟﻠﻤﻨﺰل‪ ،‬اﻟﻤﺮآب(‪:‬‬
‫‪Anti-theft alarm (in working order):‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺟﻬﺎز إﻧﺬار ﺿﺪ اﻟﺴﺮﻗﺔ )ﻓﻲ ﺣﺎﻟﺔ ﻋﻤﻞ ﺟ ﱢﻴﺪة(‪:‬‬
‫‪Anti-lock braking system:‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻧﻈﺎم ﻣﻜﺎﺑﺢ ﻣﺎﻧﻊ ﻟ‪Â‬ﻧﺰﻻق؟‬
‫‪Automatic braking system (to prevent or reduce impact of imminent collision):‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻧﻈﺎم ﻣﻜﺎﺑﺢ أوﺗﻮﻣﺎﺗﻴﻜﻲ ) ﻟﻤﻨﻊ وﻗﻮع ا ﺻﻄﺪام اﻟﻮﺷﻴﻚ أو اﻟﺤﺪ ﻣﻦ آﺛﺎره(‪ :‬ﻧﻌﻢ‬
‫?‪Cruise Control‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺟﻬﺎز ﻣﺜ ﱢﺒﺖ اﻟﺴﺮﻋﺔ؟‬
‫?‪Adaptive Cruise control‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫اﻟﺘﻜﻴﻔﻲ )اﻟﻔﻌﱠ ﺎل(؟‬
‫‪Ç‬‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺟﻬﺎز ﻣﺜ ﱢﺒﺖ اﻟﺴﺮﻋﺔ‬
‫?‪Rear parking sensors‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ اﻟﺤﺴﺎﺳﺎت اﻟﺨﻠﻔﻴﺔ ﻟﻠﻤﻮاﻗﻒ؟‬
‫?‪Front Sensors‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﺣﺴﺎﺳﺎت أﻣﺎﻣﻴﺔ؟‬
‫?‪Front Camera‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻛﺎﻣﻴﺮا أﻣﺎﻣﻴﺔ؟‬
‫?‪Rear Camera‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻛﺎﻣﻴﺮا ﺧﻠﻔﻴﺔ؟‬
‫?‪360-degree Camera‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻛﺎﻣﻴﺮا ذات اﻟـ ‪ ٣٦٠‬درﺟﺔ؟‬
‫‪Fire extinguisher (Commercial vehicles only):‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ ﻃﻔﺎﻳﺔ ﺣﺮﻳﻖ )ﻟﻠﻤﺮﻛﺒﺎت اﻟﺘﺠﺎرﻳﺔ ﻓﻘﻂ(؟‬
‫‪Modification in the car? (details):‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫‪Yes‬‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ اﻟﻤﺮﻛﺒﺔ ﺑﻬﺎ أي ﺗﻌﺪﻳﻼت؟ )ذﻛﺮ اﻟﺘﻔﺎﺻﻴﻞ(‪:‬‬
‫‪Vehicle Axle Weight (from commercial vehicles only):‬‬ ‫وزن ﻣﺤﺎور اﻟﻌﺠﻼت )ﻟﻠﻤﺮﻛﺒﺎت اﻟﺘﺠﺎرﻳﺔ ﻓﻘﻂ(؟‬
‫‪Mileage expected to be driven per year:‬‬ ‫ﻋﺪد اﻣﻴﺎل اﻟﻤﺘﻮﻗﻊ ﻗﻄﻌﻬﺎ ﻛﻞ ﺳﻨﺔ‪:‬‬

‫‪GENERAL INFORMATION‬‬ ‫ﻣﻌﻠﻮﻣﺎت ﻋﺎﻣﺔ‬

‫‪Usage‬‬ ‫اﻻﺳﺘﻌﻤﺎل‬

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

‫‪4-2‬‬
Private Car Third Party Liability Only ‫ﻃﻠﺐ ﺗﺄﻣﻴﻦ اﻟﻤﺴﺌﻮﻟﻴﺔ ﺿﺪ اﻟﻐﻴﺮ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬
Hypothecation (Financial Ownership interest, if any) ‫ﻣﺴﺘﻔﻴﺪ آﺧﺮ أو أي ﺷﺨﺺ ﻟﻪ ﻣﺼﻠﺤﺔ ﻣﺎﻟﻴﺔ إن وﺟﺪ‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
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. .‫إذا ﻛﺎﻧﺖ ا ﺟﺎﺑﺔ ﺑﻨﻌﻢ ﻳﺮﺟﻰ إﻋﻄﺎء اﺳﻤﺎء وﺗﺎرﻳﺦ اﻟﻤﻴﻼد وأرﻗﺎم رﺧﺺ اﻟﻘﻴﺎدة‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
Were you qualified for the discount of not having any claim in ‫ﻫﻞ ﻛﻨﺖ ﺗﺤﺼﻞ ﻋﻠﻰ ﺧﺼﻢ ﻋﺪم وﺟﻮد ﻣﻄﺎﻟﺒﺎت ﻓﻲ ﺷﺮﻛﺎت‬
previous insurance companies? ‫اﻟﺘﺄﻣﻴﻦ اﻟﺴﺎﺑﻘﺔ؟‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
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? ‫ﻫﻞ ﻟﺪﻳﻚ ﺳﻴﺎرات أﺧﺮى ﻣﺆﻣﻨﺔ ﻟﺪى اﻟﺸﺮﻛﺔ؟‬
If The Answer is yes, please Provide details of the vehicle?
(‫)ﻓﻲ ﺣﺎل ا ﺟﺎﺑﺔ ﺑﻨﻌﻢ ﻳﺮﺟﻰ ﺗﻘﺪﻳﻢ ﺗﻔﺎﺻﻴﻞ ﻋﻦ اﻟﻤﺮﻛﺒﺔ‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
Are any Those who drive the car suffers From Physical disability? ‫ﻫﻞ أي ﻣﻤﻦ ﻳﻘﻮدون اﻟﺴﻴﺎرة ﻳﻌﺎﻧﻲ ﻣﻦ إﻋﺎﻗﺔ ﺟﺴﺪﻳﺔ؟‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
Are you involved in any Traffic offence ? ‫ﻫﻞ ﺳﺒﻖ وأن ﺗﻌﺮﺿﺘﻢ ي ﻣﺨﺎﻟﻔﺎت ﻣﺮورﻳﺔ؟‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
Are you are involved in any traffic accident during the past three ‫ ﻓﻲ أي ﺣﺎدث ﻣﺮوري ﺧﻼل اﻋﻮام اﻟﺜﻼث‬Í‫ﻫﻞ ﻛﻨﺖ ﻃﺮﻓ‬
years? ‫اﻟﻤﺎﺿﻴﺔ؟‬
No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬

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: :‫( ا ﻟﺘﺰام 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 ‫ا ﺻﺎﺑﺎت ﻟﻠﻄﺮف اﻟﺜﺎﻟﺚ‬ ‫أﺿﺮار اﻟﻄﺮف اﻟﺜﺎﻟﺚ‬ ‫اﺿﺮار‬ ‫ﺗﺎرﻳﺦ اﻟﺤﺎدث‬
Notes Grand Total Injury to third Party Damages to TP Damages Date of accident

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

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Private Car Third Party Liability Only ‫ﻃﻠﺐ ﺗﺄﻣﻴﻦ اﻟﻤﺴﺌﻮﻟﻴﺔ ﺿﺪ اﻟﻐﻴﺮ ﻟﻠﻤﺮﻛﺒﺎت اﻟﺨﺎﺻﺔ‬
DECLARATION ‫إﻗﺮار‬

I/We hereby, the undersigned agree to authorize Aljazira Takaful Ta’awuni Co.

to inquire with Najm for Insurance Services Company and Government

entities and companies licensed & approved by Saudi Arabian Monetary ُ

Authority (SAMA) about all information and data related to any insurance

claims that I was involve in, whether in respect of the vehicle or driver, and I

agree as well to grant Najm for Insurance Services Company the right to

disclose and share any information with insurance or reinsurance ُ ُ

companies or Insurance Profession owners licensed and approved by Saudi

Central Bank (SAMA) of all information and data of my vehicles,

insurance claims and insurance policies issued in the past or

forthcoming.

I/We the Hereby, undersigned (Agent/Authorized person (on behalf of the

establishment/Company) agree to provide Aljazira Takaful Ta’awuni company

with any information that it requires for issuing an insurance policy and/or

auditing and/or administering my accounts and facilities therewith.

I/We authorize it to obtain, collect, disclose and share any information as it

deems necessary or in need for issuing an insurance policy of all types

(active and expired) and/or any other financial obligation from/to the Saudi

Credit Bureau (SIMAH) through the membership agreement signed with the

company.

I /we , hereby declare/agree

A) That the information and the details disclosed in the proposal Are:

1. Correct to the best of my/our knowledge. 1

2. Will form the basis of the contract with the company. 2
B) To the terms, exclusions and conditions of the policy which I/we have

read.

Date Driver Name Name of the applicant

Signature Signature

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