CONDITIONAL ASSIGNMENT ‫إﻗﺮار ﺗﻨﺎزل ﻣﺸﺮوط‬

Application No. / Plan No. ‫ رﻗﻢ اﻟﺨﻄﺔ‬/ ‫رﻗﻢ اﻟﻄﻠﺐ‬

I / We, ________________________________________________ (Plan Holder) __________________________________________ ،‫ ﻧﺤﻦ‬/‫أﻧﺎ‬

the owner(s) of Plan No: _________________________________, issued by _______________________ ‫)ﺣﺎﻣﻞ اﻟﺨﻄﺔ( ﻣﺎﻟﻚ اﻟﻮﺛﻴﻘﻪ رﻗﻢ‬
SALAMA - Islamic Arab Insurance Company, hereby conditionally ‫اﻟﺼﺎدرة ﻣﻦ اﻟﺸﺮﻛﺔ اﻹﺳﻼﻣﻴﺔ اﻟﻌﺮﺑﻴﺔ ﻟﻠﺘﺄﻣﻴﻦ – ﺳﻼﻣﺔ أﻗﺮ‬
assign the Sum Covered of AED / USD ____________________________ to ‫ﺑﻤﻮﺟﺒﻪ ﺑﺄﻧﻨﻲ ﻗﺪ ﺗﻨﺎزﻟﺖ ﺑﺸﻜﻞ ﻣﺸﺮوط ﻋﻦ ﻣﺒﻠﻎ اﻟﺘﺄﻣﻴﻦ واﻟﺬي‬
_____________________ (Assignee), and to his / her / their nominee(s), ‫ دوﻻر أﻣﺮﻳﻜﻲ إﻟﻰ‬/‫ﻗﺪره ___________________ درﻫﻢ اﻣﺎراﺗﻲ‬
heir(s), executor(s), administrator(s) and assignee(s) has the right to
(‫________________________________________)اﻟﻤﺘﻨﺎزل ﻟﻪ‬
receive assigned benefit payable and related information under the
ً
‫ﻧﺎﺋﺒﺎ ﻋﻨﻪ وﻟﻮرﺛﺘﻪ وأﻣﻴﻦ وﺻﻴﺘﻪ وﺣﺎرﺳﻪ اﻟﻘﻀﺎﺋﻲ‬ ‫وﻟﻤﻦ ﻳﺴﻤﻴﻪ‬
Plan Terms and Conditions. The Plan Holder however, retains owner-
ship of the Plan. ‫ ﻟﻬﻢ اﺳﺘﻼم ﻣﺒﻠﻎ اﻟﺘﺄﻣﻴﻦ‬/ ‫ ﺑﺤﻴﺚ ﻳﺤﻖ ﻟﻪ‬،‫وﻟﻤﻦ ﻳﺘﻨﺎزل ﻟﻪ‬
‫اﻟﻤﺘﻨﺎزَ ل ﻋﻨﻪ و أن ﻳﺘﻠﻘﻮا اﻟﻤﻌﻠﻮﻣﺎت ذات اﻟﺼﻠﺔ ﺑﻤﻮﺟﺐ أﺣﻜﺎم‬
ُ
I / We hereby solemnly confirm that no dual assignment will be made .‫ ﻳﺤﺘﻔﻆ ﺻﺎﺣﺐ اﻟﺨﻄﺔ ﺑﻤﻠﻜﻴﺔ اﻟﺨﻄﺔ‬، ‫ وﻣﻊ ذﻟﻚ‬.‫وﺷﺮوط اﻟﺨﻄﺔ‬
for the aforementioned Sum Covered and that this Plan is otherwise
free from all encumbrances till such time as this assignment remains ‫ ﻋﺪم وﺟﻮد ﺗﻨﺎزل ﻣﺰدوج‬،‫ﻛﻤﺎ أؤﻛﺪ )ﻧﺆﻛﺪ( ﺑﻤﻮﺟﺒﻪ وﺑﺸﻜﻞ ﻗﺎﻃﻊ‬
‫ﻟﻤﺒﻠﻎ اﻟﺘﺄﻣﻴﻦ اﻟﻤﺬﻛﻮر أﻋﻼه وأن اﻟﺨﻄﺔ اﻟﻤﺬﻛﻮرة ﻻ ﺗﺨﻀﻊ ﻷي‬
valid and in-force.
‫ﻧﻮع آﺧﺮ ﻣﻦ اﻟﺤﺠﺰ أو اﻟﺮﻫﻦ ﻃﻮال اﻟﻮﻗﺖ اﻟﺬي ﻳﺒﻘﻰ ﻓﻴﻪ ﻫﺬا‬
ً
.‫ﺻﺎﻟﺤﺎ وﺳﺎري اﻟﻤﻔﻌﻮل‬ ‫اﻟﺘﻨﺎزل‬
I / We also agree, understand & acknowledge that this Plan is being
assigned by me / us and that SALAMA - Islamic Arab Insurance ً
‫ أﻧﻨﺎ ﺑﻬﺬا‬/‫اﻳﻀﺎ وأدرك )ﻧﺪرك( وأﻗﺮ )ﻧﻘﺮ( أﻧﻨﻲ‬ (‫وأواﻓﻖ )ﻧﻮاﻓﻖ‬
Company assumes no responsibility as to the validity, effect and ‫أﺗﻨﺎزل )ﻧﺘﻨﺎزل( ﻋﻦ ﻫﺬه اﻟﺨﻄﺔ وأن اﻟﺸﺮﻛﺔ اﻻﺳﻼﻣﻴﺔ اﻟﻌﺮﺑﻴﺔ‬
sufficiency of this assignment made by me / us in favor of the ‫ﻟﻠﺘﺄﻣﻴﻦ – ﺳﻼﻣﺔ ﻻ ﺗﺘﺤﻤﻞ أﻳﺔ ﻣﺴﺆوﻟﻴﺔ ﺗﺠﺎه ﺻﻼﺣﻴﺔ وﺗﺄﺛﻴﺮ‬
Assignee. .‫اﻟﻤﺘﻨﺎزَ ل ﻟﻪ‬
ُ ‫ﻧﺤﺮره ﻟﺼﺎﻟﺢ‬/ ‫وﻛﻔﺎﻳﺔ ﻫﺬا اﻟﺘﻨﺎزل اﻟﺬي اﺣﺮره‬

‫ ﻓﻰ‬:‫ﻣﺆرخ‬ ‫ﻳﻮم‬ ‫ﺳﻨﺔ‬ ‫ﻳﻮم‬ ‫اﻟﻤﻜﺎن‬

Dated: This Day of In the year at (Place)

‫ﺗﻮﻗﻴﻊ ﺣﺎﻣﻞ اﻟﺨﻄﺔ‬

‫ﺗﻮﻗﻴﻊ اﻟﻌﻀﻮ اﻟﻤﻐﻄﻰ اﻷول‬ ‫ﺗﻮﻗﻴﻊ اﻟﻌﻀﻮ اﻟﻤﻐﻄﻰ اﻟﺜﺎﻧﻲ‬ ً
(‫ﻣﺨﺘﻠﻔﺎ ﻋﻦ اﻟﻌﻀﻮ اﻟﻤﻐﻄﻰ اﻷول أو اﻟﻌﻀﻮ اﻟﻤﻐﻄﻰ اﻟﺜﺎﻧﻲ‬ ‫)إذا ﻛﺎن‬
Signature of First Covered Member Signature of Second Covered Member Signature of Plan Holder (If different from First Covered Member
or Second Covered Member)

‫اﻟﺘﺎرﻳﺦ‬ ‫اﻟﺘﺎرﻳﺦ‬ ‫اﻟﺘﺎرﻳﺦ‬

Date Date Date

‫ اﻟﻤﻨﻘﻮل إﻟﻴﻪ‬/‫اﻟﻤﺘﻨﺎزَ ل ﻟﻪ‬

ُ ‫ﺗﻮﻗﻴﻊ وﺧﺘﻢ‬ ‫ﺗﻮﻗﻴﻊ اﻟﺸﺎﻫﺪ‬
Signature & Stamp of Assignee / Transferee Signature of Witness

‫اﻻﺳﻢ‬ ‫اﻻﺳﻢ‬
Name: Name:
FT-CS (CAF) - 2018-10

‫اﻟﻠﻘﺐ‬ ‫اﻟﻠﻘﺐ‬
Designation: Designation:

‫ﺗﻮﻗﻴﻊ‬ ‫اﻟﺘﺎرﻳﺦ‬ ‫ﺗﻮﻗﻴﻊ‬ ‫اﻟﺘﺎرﻳﺦ‬

Signature: Date Signature: Date

+٩٧١ ٤ ٣٥٧ ٧٠٠٧ : ‫ ﻓﺎﻛﺲ‬،+٩٧١ ٤ ٤٠٧ ٩٩٩٩ : ‫ ﻫﺎﺗﻒ‬،‫ اﻹﻣﺎرات اﻟﻌﺮﺑﻴﺔ اﻟﻤﺘﺤﺪة‬،‫ دﺑﻲ‬، ١٠٢١٤ ‫ ب‬.‫ ص‬- ‫ﺳﻼﻣﺔ‬
SALAMA - P. O. Box 10214 ,Dubai, United Arab Emirates. Tel : +971 4 407 9999, Fax: +971 4 357 7007
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