‫‪ POLICY SCHEDULE‬ﺟﺪول اﻟﻮﺛﻴﻘﺔ‬

‫‪TYPE OF POLICY:‬‬ ‫‪Third Party / A-ALAM-1-B-10-026‬‬ ‫‪POLICY NUMBER:‬‬ ‫‪1211486816‬‬

‫ﻧ ﻮ ع اﻟﺘ ﻐ ﻄﻴ ﺔ‬ ‫وﺛﻴ ﻘ ﺔ ا ﻟﺘ ﺄ ﻣﻴ ﻦ ا ﻟ ﻄ ﺮ ف ا ﻟﺜ ﺎ ﻟ ﺚ‬ ‫ر ﻗ ﻢ ا ﻟ ﻮﺛﻴ ﻘ ﺔ‬
‫‪CERTIFICATE:‬‬ ‫‪1211486816‬‬
‫ر ﻗ ﻢ اﻟ ﺸ ﻬﺎدة‬
‫‪NAME OF‬‬ ‫ﻓ ﻼ ح ﺑ ﻦ ﻋ ﺒ ﺪا ﻟ ﻠ ﻪ ﺑ ﻦ ﺧ ﺎ ﺗ ﻢ ا ﻟ ﻤ ﻄ ﻴ ﺮ ي‬ ‫‪DATE OF ISSUE:‬‬ ‫‪02/06/2025‬‬
‫‪INSURED:‬‬ ‫ﺗ ﺎ ر ﻳ ﺦ ا ﻹ ﺻ ﺪا ر‬
‫ا ﺳ ﻢ اﻟ ﻤ ﺆ ﻣ ﻦ‬
‫‪INSURED ID NO.:‬‬ ‫‪1007838467‬‬
‫ر ﻗ ﻢ اﻟ ﻤ ﺆ ﻣ ﻦ‬
‫‪MOBILE NO.:‬‬ ‫‪0555154075‬‬ ‫‪BUSINESS CODE:‬‬ ‫ﺗﺎﻣﻴﻨﻲ ‪Tameeni/‬‬
‫ر ﻗ ﻢ ا ﻟ ﺠ ﻮا ل‬ ‫ر ﻗ ﻢ اﻟ ﻘ ﻄﺎ ع‬
‫‪PREMIUM (SAR):‬‬ ‫‪644.00‬‬
‫اﻟ ﻤ ﺠ ﻤ ﻮ ع‬
‫‪NATIONAL‬‬ ‫ﺑﺸﺮ ﺑﻦ اﻟﺤﺎرث ‪ -‬ﺣﻲ اﻟﻤﻨﺎر ‪ -‬ﻋﻨﻴﺰة ‪7057 - - 56439 -‬‬ ‫‪POLICY FEE (SAR):‬‬
‫‪ADDRESS:‬‬ ‫‪3193‬‬ ‫ر ﺳ ﻮ م ا ﻟ ﻮﺛﻴ ﻘ ﺔ‬
‫ا ﻟ ﻌ ﻨ ﻮا ن ا ﻟ ﻮ ﻃ ﻨ ﻲ‬
‫‪VAT Standard 15%:‬‬ ‫‪96.60‬‬
‫ﻗﻴ ﻤ ﺔ ا ﻟ ﻀ ﺮﻳﺒ ﺔ ا ﻟ ﻤ ﻀ ﺎ ﻓ ﺔ‬
‫‪Total PAYABLE (SAR):‬‬ ‫‪740.60‬‬
‫اﻟ ﻤ ﺠ ﻤ ﻮ ع اﻟ ﻜﻠ ﻲ‬

‫‪INSURED AND AUTHORIZED DRIVERS‬‬ ‫اﻟ ﻤ ﺆ ﻣ ﻦ ﻟ ﻪ واﻟ ﺴﺎﺋ ﻘﻴ ﻦ اﻟ ﻤ ﺴ ﻤﻴﻴ ﻦ‬

‫اﺳﻢ‪Name/‬‬ ‫رﻗﻢ ﻫﻮﻳﺔ ‪ID No./‬‬ ‫اﻟﻌﻤﺮ ‪Age/‬‬ ‫اﻟﺠﻨﺲ ‪Gender/‬‬ ‫‪Marital Status /‬‬ ‫‪Occupation /‬‬ ‫‪Driver License‬‬
‫اﻟ ﺤﺎﻟ ﺔ ا ﻹ ﺟﺘ ﻤﺎ ﻋﻴ ﺔ‬ ‫اﻟ ﻤ ﻬﻨ ﺔ‬ ‫ﻧﻮع رﺧﺼﺔ ‪Type /‬‬
‫اﻟ ﻘﻴﺎ د ة‬
‫ﻓ ﻼ ح ﺑ ﻦ ﻋ ﺒ ﺪا ﻟ ﻠ ﻪ ﺑ ﻦ‬ ‫‪1007838467‬‬ ‫‪52‬‬ ‫ذﻛﺮ‬ ‫ﻣﺘ ﺰ و ج‬ ‫أﺧﺮ ى‬ ‫ﺧﺎ ﺻ ﺔ‬
‫ﺧ ﺎﺗ ﻢ ا ﻟ ﻤ ﻄﻴ ﺮ ي‬
‫ﻣﻌﺎذ ﻓ ﻼ ح ﺑ ﻦ‬ ‫‪1081341156‬‬ ‫‪31‬‬ ‫ذﻛﺮ‬ ‫أﺧﺮ ى‬ ‫ﺧﺎ ﺻ ﺔ‬
‫ﻋ ﺒ ﺪا ﻟ ﻠ ﻪ ا ﻟ ﻌ ﻘ ﻴ ﻠ ﻲ‬

‫‪VEHICLE DETAILS‬‬ ‫ﺗ ﻔﺎ ﺻﻴ ﻞ اﻟ ﻤ ﺮ ﻛﺒ ﺔ‬
‫‪ / REG NO‬رﻗﻢ اﻟﻠﻮﺣﺔ‬ ‫‪ / COLOUR‬اﻟﻠﻮن‬ ‫‪ / CHASSIS NUMBER‬رﻗﻢ‬ ‫‪CUSTOM/SEQUENCE‬‬ ‫‪ / REG EXPIRY DATE‬ﺗﺎرﻳﺦ‬
‫اﻟ ﻬﻴ ﻜ ﻞ‬ ‫‪ .No‬رﻗﻢ ﺟﻤﺮﻛﻲ‪ /‬ﺗﺴﻠﺴﻠﻲ‬ ‫اﻧﺘ ﻬ ﺎ ء ر ﺧ ﺼ ﺔ ا ﻟ ﺴﻴ ﺮ‬
‫د ر ر ‪4576‬‬ ‫اﺣﻤﺮ‬ ‫‪JM7BN1SZ8J1187095‬‬ ‫‪671275710‬‬ ‫‪03/05/1447‬‬
‫ﻧﻮع‪TYPE OF BODY /‬‬ ‫اﻻﺳﺘﺨﺪام ‪USE /‬‬ ‫‪MAKE AND MODEL /‬‬ ‫ﺳﻨﺔ اﻟﺼﻨﻊ‪YEAR /‬‬ ‫ﻋﺪد‪SEATING CAPACITY/‬‬
‫اﻟ ﻬﻴ ﻜ ﻞ‬ ‫ﻃ ﺮا ز و ﻣ ﻮ د ﻳ ﻞ‬ ‫اﻟ ﺮﻛﺎ ب‬
‫ﺳﻴﺎ ر ة ﺻ ﻐﻴ ﺮ ة ‪ 4‬ﺑﺎ ب‬ ‫ﺷﺨ ﺼﻲ‬ ‫‪ 3‬ﺳ ﻴ ﺪا ن ‪ /‬ﻣ ﺎ ز دا‬ ‫‪2018‬‬ ‫‪5‬‬
‫ﻧﺎﻗﻞ ‪TRANSMISSION /‬‬ ‫ﻣﻜﺎن اﻻﻳﻘﺎف ﻟﻴﻼ ُ ‪PARKING LOCATION AT NIGHT /‬‬ ‫ﻟﺘﻌﺪﻳﻼت ﻋﻠﻰ اﻟﻤﺮﻛﺒﺔ ‪VEHICLE MODIFICATIONS/‬‬
‫اﻟ ﺤ ﺮﻛ ﺔ‬
‫‪Automatic‬‬ ‫اﻟ ﺸﺎر ع‬

‫ﻓﺘﺮة اﻟﺘﻐﻄﻴﺔ\ ‪PERIOD OF INSURANCE‬‬ ‫ﻣﻦ \‪FROM 03/06/2025‬‬ ‫اﻟﻰ ‪To \ 02/06/2026 :‬‬
‫‪ :‬اﻟﺘﺄ ﻣﻴﻨﻴ ﺔ‬

‫‪LIMIT OF LIABILITY‬‬ ‫ﺣ ﺪ و د اﻟ ﻤ ﺴ ﺆ وﻟﻴ ﺔ‬

‫‪Third Party Liability (Physical and‬‬ ‫‪SAR 10,000,000/-‬‬ ‫‪SAR 10,000,000/-‬‬ ‫ﻣ ﺴ ﺆ و ﻟ ﻴ ﺔ ا ﻟ ﻄ ﺮ ف ا ﻟ ﺜ ﺎ ﻟ ﺚ )ا ﻷ ﺿ ﺮا ر‬
‫‪(Material Damages‬‬ ‫ا ﻟ ﻤ ﺎ د ﻳ ﺔ وا ﻟ ﻤ ﺎ ﻟ ﻴ ﺔ (‬
‫‪Territorial Limits‬‬ ‫‪Kingdom of Saudi Arabia‬‬ ‫ا ﻟ ﻤ ﻤﻠ ﻜ ﺔ ا ﻟ ﻌ ﺮﺑﻴ ﺔ ا ﻟ ﺴ ﻌ ﻮ دﻳ ﺔ‬ ‫ا ﻟ ﺤ ﺪ و د ا ﻟ ﺠ ﻐ ﺮا ﻓ ﻴ ﺔ‬
‫‪Limitation of Use‬‬ ‫‪The insured must not use the‬‬ ‫ﻳ ﺠ ﺐ ﻋﻠ ﻰ ﺍﻟ ﻤ ﺆ ﻣ ﻦ ﻟ ﻪ ﺍ ﻻ ﻳ ﺴﺘ ﻌ ﻤ ﻞ‬ ‫ﻗﻴ ﻮ د ا ﻻ ﺳﺘ ﻌ ﻤﺎ ل‬
‫‪vehicle except for the purpose for‬‬ ‫ﺍ ﻟ ﺴﻴ ﺎ ﺭ ﺓ ﺇ ﻻ ﻟﻠ ﻐ ﺮ ﺽ ﺍ ﻟ ﻤ ﺮ ﺧ ﺺ ﻣ ﻦ ﺃ ﺟﻠ ﻪ‪.‬‬
‫‪.which it is licensed‬‬

‫‪OPTIONAL COVERS‬‬ ‫اﻟﺘ ﻐ ﻄﻴﺎ ت ا ﻻ ﺧﺘﻴﺎ رﻳ ﺔ‬

 Benefits Covered Benefits Covered
Personal accident benefit for the driver ‫ ﻻ‬/ No Roadside Assistance ‫ ﻻ‬/ No
‫ﺗ ﻐ ﻄ ﻴ ﺔ ا ﻟ ﺤ ﻮا د ث ا ﻟ ﺸ ﺨ ﺼ ﻴ ﺔ ﻟ ﻠ ﺴ ﺎ ﺋ ﻖ‬ ‫ﺧ ﺪ ﻣ ﺔ ا ﻟ ﻤ ﺴ ﺎ ﻋ ﺪ ة ﻋﻠ ﻰ ا ﻟ ﻄ ﺮﻳ ﻖ‬
Personal accident benefit for passengers ‫ ﻻ‬/ No
‫ﺗ ﻐ ﻄ ﻴ ﺔ ا ﻟ ﺤ ﻮا د ث ا ﻟ ﺸ ﺨ ﺼ ﻴ ﺔ ﻟ ﻠ ﺮ ﻛ ﺎ ب‬

‫ رﻗﻢ اﻟﻮﺛﻴﻘﺔ‬/ Policy No: 1211486816 ‫ اﻟﻤﺆﻣﻦ‬/ Insured: ‫ﻓ ﻼ ح ﺑ ﻦ ﻋ ﺒ ﺪا ﻟ ﻠ ﻪ ﺑ ﻦ ﺧ ﺎ ﺗ ﻢ ا ﻟ ﻤ ﻄ ﻴ ﺮ ي‬

Personal Accident Benefit ‫ﺗ ﻐ ﻄﻴ ﺔ اﻟ ﺤ ﻮا د ث اﻟ ﺸ ﺨ ﺼﻴ ﺔ‬

Personal Accidents benefit is for an accident involving the Insured ‫ﻣ ﻨ ﻔ ﻌ ﺔ ا ﻟ ﺤ ﻮا د ث ا ﻟ ﺸ ﺨ ﺼ ﻴ ﺔ ﻟ ﻠ ﺤ ﻮا د ث ا ﻟ ﺘ ﻲ ﺗ ﻀ ﺮ ر ﻓ ﻴ ﻬ ﺎ ﺟ ﺴ ﻢ ا ﻟ ﻤ ﺮ ﻛ ﺒ ﺔ و ﺗ ﺸ ﻤ ﻞ‬
Motor Vehicle and is subject to the following: ‫ا ﻟ ﻮ ﻓ ﺎ ة وا ﻻ ﺿ ﺮا ر ا ﻟ ﺠ ﺴ ﺪ ﻳ ﺔ وا ﻟ ﻤ ﺼ ﺎ ر ﻳ ﻒ ا ﻟ ﻄ ﺒ ﻴ ﺔ ﻟ ﻠ ﺴ ﺎ ﺋ ﻖ وا ﻟ ﺴ ﺎ ﺋ ﻖ ا ﻟ ﻤ ﺴ ﻤ ﻰ و ﻓ ﻖ‬
:‫ا ﻟ ﺘ ﺎ ﻟ ﻲ‬
Driver coverage (if opted) is for Insured or Authorized
Driver(s) only. . ‫ﺗ ﻐ ﻄﻴ ﺔ ا ﻟ ﺴ ﺎﺋ ﻖ ) ﻋﻨ ﺪ ا ﺧﺘﻴ ﺎ ر ﻫ ﺎ ( ﺗﺘ ﻀ ﻤ ﻦ ﺗ ﻐ ﻄﻴ ﺔ ا ﻟ ﺴ ﺎﺋ ﻖ ﻓ ﻘ ﻂ‬
Passenger coverage (if opted) is for any non-fare paying ‫ﺗ ﻐ ﻄ ﻴ ﺔ ا ﻟ ﺮا ﻛ ﺐ ) ﻋ ﻨ ﺪ ا ﺧ ﺘ ﻴ ﺎ ر ﻫ ﺎ ( و ﻳ ﻘ ﺼ ﺪ ﺑ ﻬ ﺎ أ ي را ﻛ ﺐ ﻓ ﻲ ﻣ ﺮ ﻛ ﺒ ﺔ ا ﻟ ﻤ ﺆ ﻣ ﻦ‬
person travelling in the Insured Motor Vehicle between the .‫ ﺳﻨﺔ‬65 ‫ ﺳﻨﺔ ﺣﺘﻰ‬16 ‫ﻟﻪ وﻳﺒﻠﻎ ﻣﻦ اﻟﻌﻤﺮ ﻣﺎ ﺑﻴﻦ‬
Lower Age Limit and Upper Age Limit of 16 years and 65
years respectively. :‫و ﺻ ﻒ ﻟ ﻠ ﻤ ﻨ ﺎ ﻓ ﻊ وا ﻟ ﻤ ﺒ ﺎ ﻟ ﻎ ا ﻟ ﻤ ﻘ ﺎ ﺑ ﻠ ﺔ ﻟ ﻬ ﺎ ﻓ ﻲ ﺣ ﺎ ﻟ ﺔ ا ﻟ ﺘ ﻌ ﻮ ﻳ ﺾ‬

Description of Benefits and the respective amount(s) is as follows:

Benefit Description Amount (SAR) ‫ﻧ ﻮ ع اﻟ ﻤﻨ ﻔ ﻌ ﺔ‬
Death 100,000 ‫اﻟ ﻮ ﻓﺎة‬
Permanent Disablement (any occupation) 100,000 ‫ا ﻟ ﻌ ﺠ ﺰ ا ﻟ ﺪا ﺋ ﻢ ا ﻟ ﻜ ﻠ ﻲ أ و ا ﻟ ﺠ ﺰ ﺋ ﻲ ا ﻟ ﺬ ي ﻳ ﻔ ﻘ ﺪ ا ﻟ ﻤ ﺆ ﻣ ﻦ‬
‫ أ و‬، ‫ﻟ ﻪ ﺑ ﺴ ﺒ ﺒ ﻪ ا ﻟ ﻘ ﺪ ر ة ﻋ ﻠ ﻰ ﻣ ﻤ ﺎ ر ﺳ ﺔ أ دا ء أ ي ﻋ ﻤ ﻞ‬
‫و ﻇﻴ ﻔ ﺔ أ و ﻣ ﻬﻨ ﺔ ﺑ ﻤ ﻮ ﺟ ﺐ ﺗ ﻘ ﺮﻳ ﺮ ﻟ ﺠﻨ ﺔ ﻃﺒﻴ ﺔ ﻣ ﻌﺘ ﻤ ﺪ ة‬
Total loss by physical severance at or above 100,000 ‫ﺑﺘ ﺮ ا ﻟﻴ ﺪﻳ ﻦ ﻣ ﻦ ﻣﻨ ﻄ ﻘ ﺔ ا ﻟ ﺮ ﺳ ﻎ أ و ﺑﺘ ﺮ ا ﻟ ﻘ ﺪ ﻣﻴ ﻦ ﻣ ﻦ‬
the wrist or ankle of both hands or both feet ‫اﻟﻜﺎ ﺣ ﻞ‬
or one hand and one foot
Total loss by physical severance at or above 50,000 ‫ﺑ ﺘ ﺮ ﻳ ﺪ وا ﺣ ﺪ ة ﻣ ﻦ ﻣ ﻨ ﻄ ﻘ ﺔ ا ﻟ ﺮ ﺳ ﻎ أ و ﻗ ﺪ م وا ﺣ ﺪ ة ﻣ ﻦ‬
the wrist or ankle of one hand or one foot ‫اﻟﻜﺎ ﺣ ﻞ‬
Permanent total loss of sight in both eyes 100,000 ‫ﻓ ﻘ ﺪا ن ﺗ ﺎ م و دا ﺋ ﻢ ﻟ ﻠ ﺒ ﺼ ﺮ ﻓ ﻲ ﻛ ﻼ ا ﻟ ﻌ ﻴ ﻨ ﻴ ﻦ‬
Permanent toal loss of sight in one eye 50,000 ‫ﻓ ﻘ ﺪا ن ﺗ ﺎ م و دا ﺋ ﻢ ﻟ ﻠ ﺒ ﺼ ﺮ ﻓ ﻲ ﻋ ﻴ ﻦ وا ﺣ ﺪ ة‬
Reimbursement of medical and surgical 25,000 ‫ﻧ ﻔ ﻘ ﺎ ت ا ﻟ ﻌ ﻼ ج ا ﻟ ﻄ ﺒ ﻲ وا ﻟ ﺠ ﺮا ﺣ ﻲ ا ﻟ ﻤ ﺘ ﻜ ﺒ ﺪ ة‬
treatment expenses
Policy/ Najm Report ‫ﺗ ﻘ ﺮﻳ ﺮ اﻟ ﻤ ﺮور أو ﻧ ﺠ ﻢ‬
Police / Najm report is required for all claims ‫ ﻧ ﺠ ﻢ ﺿ ﺮ و ر ي ﻓ ﻲ ﺟ ﻤﻴ ﻊ ا ﻟ ﻤ ﻄ ﺎ ﻟﺒ ﺎ ت‬/ ‫ﻳ ﻌﺘﺒ ﺮ ﺗ ﻘ ﺮﻳ ﺮ ا ﻟ ﻤ ﺮ و ر‬
Other Terms and Conditions ‫ﺷ ﺮو ط و أ ﺣ ﻜﺎ م آ ﺧ ﺮ ى‬
All other terms and conditions are as per the Company’s Third Party ‫ﺗ ﺄ ﺗ ﻲ ا ﻟ ﺸ ﺮ و ط وا ﻷ ﺣ ﻜ ﺎ م ا ﻷ ﺧ ﺮ ى و ﻓ ﻘ ﺎ ً ﻟ ﺼ ﻴ ﻐ ﺔ و ﺛ ﻴ ﻘ ﺔ ا ﻟ ﺘ ﺄ ﻣ ﻴ ﻦ ا ﻟ ﺸ ﺎ ﻣ ﻠ ﺔ ﻋ ﻠ ﻰ‬
Motor Insurance Policy wording. ‫اﻟ ﻤ ﺮ ﻛﺒﺎ ت اﻟ ﺨﺎ ﺻ ﺔ ﺑﺎﻟ ﺸ ﺮ ﻛ ﺔ‬
Any Other Disclosure / ‫اﻹﻓﺼﺎﺣﺎت اﻷﺧﺮى‬

‫ ﺍﻟﺸﺮﻛﺔ ﻟﻴﭭﺎ ﻟﻠﺘﺄﻣﻴﻦ‬/ Liva Insurance Company

‫ اﻟﻤﺨﻮل ﺑﺎﻟﺘﻮﻗﻴﻊ‬/ Authorized Signatory