KYC and Retail Comprehensive ‫ﻧــﻤﻮذج اﻋـﺮف ﻋـﻤﻴــﻠﻚ و ﻃﻠـﺐ‬

Motor Insurance Proposal Form ‫ﺗﺄﻣﻦﻴ اﳌﺮﻛﺒﺎت اﻟﺸﺎﻣـﻞ ﻟﻸﻓﺮاد‬

Details Of Proposer* *‫ﺑﻴﺎﻧﺎت ﻣﺎﻟﻚ اﳌﺮﻛﺒﺔ‬

Name of Proposer ‫إﺳﻢ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻦﻴ‬

Marital status Single ‫أﻋﺰب‬ Married ‫ﻣﺘﺰوج‬ ‫اﻟﺤﺎﻟﺔ اﻹﺟﺘﺎﻤﻋﻴﺔ‬

Diploma ‫دﺑﻠﻮم‬ Secondary ‫ﺛﺎﻧﻮي‬ Intermediate ‫ﻣﺘﻮﺳﻂ‬ Elementary ‫اﺑﺘﺪاﻲﺋ‬
Education Other ‫أﺧﺮى‬ PhD ‫دﻛﺘﻮراه‬ Master ‫ﻣﺎﺟﺴﺘﺮﻴ‬ Bachelor ‫ﺑﻜﺎﻟﻮرﻳﻮس‬
‫اﻟﺘﻌﻠﻴﻢ‬

Nationality Saudi ‫ﺳﻌﻮدي‬ Non-Saudi ‫ﻏﺮﻴ ﺳﻌﻮدي‬ ‫اﻟﺠﻨﺴﻴﺔ‬

ID Number ‫رﻗﻢ اﻟﻬﻮﻳﺔ‬

ID Type ‫ﻧﻮع اﻟﻬﻮﻳﺔ‬

Expiry ‫ﺗﺎرﻳﺦ اﻹﻧﺘﻬﺎء‬

Gender Female ‫اﻧﺜﻰ‬ Male ‫ذﻛﺮ‬ ‫اﻟﺠﻨﺲ‬

Date of birth ‫ﺗﺎرﻳﺦ اﳌﻴﻼد‬

Phone (Landline) ‫رﻗﻢ ﻫﺎﺗﻒ اﳌﻨﺰل‬
Mobile ‫رﻗﻢ اﻟﺠﻮال‬

Address and (WASEL) Street

Name
‫إﺳﻢ‬
‫ اﻟﺸﺎرع‬Building #
‫ﻣﺒﻨﻰ‬
‫رﻗﻢ‬
Unit #
‫وﺣﺪة‬
‫رﻗﻢ‬
‫ﻣﻌﻠﻮﻣﺎت اﻟﺴﻜﻦ‬
‫ إﺳﻢ‬District ‫إﺳﻢ‬
(‫وﺑﺮﻳﺪ )واﺻﻞ‬
City ‫ اﳌﺪﻳﻨﺔ‬Region ‫ اﳌﻨﻄﻘﺔ‬Name
Name ‫اﻟﺤﻲ‬
‫اﻟﺮﻣﺰ‬ ‫اﻟﺮﻣﺰ‬
P.O.Box ‫ب‬.‫ ص‬Postal Additional
‫ اﻟﱪﻳﺪي‬Code
Code ‫اﻹﺿﺎﰲ‬

Employer Information Employer Name ‫إﺳﻢ اﻟﴩﻛﺔ‬ ‫ﺟﻬﺔ اﻟﻌﻤﻞ‬

Address ‫اﻟﻌﻨﻮان‬

Phone Number ‫رﻗﻢ اﻟﻬﺎﺗﻒ‬

Annual Income (Approximate) ‫س‬.‫ ر‬- ‫ﻣﻌﺪل اﻟﺪﺧﻞ اﻟﺴﻨﻮي‬

Income Sources ‫ﻣﺼﺪر اﻟﺪﺧﻞ‬

(IBAN) Number ‫رﻗﻢ اﻵﺑﻴﺎن‬

Name of Bank ‫اﺳﻢ اﻟﺒﻨﻚ‬
Are you a Politically Exposed Person (PEP) or ‫ﻫﻞ اﻧﺖ ﻣﻦ اﻷﺷﺨﺎص اﳌﻜﺸﻮﻓﻦﻴ ﺳﻴﺎﺳﻴﺎً او ﺗﺮﺑﻄﻚ‬
Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﺻﻠﺔ ﻗﺮاﺑﺔ ﺑﺄﺣﺪ اﻷﺷﺨﺎص اﳌﻜﺸﻮﻓﻦﻴ ﺳﻴﺎﺳﻴﺎً ؟‬
related to Politically Exposed Person (PEP) ?
PEP Definition : Person in charge of a Senior public position in the kingdom or foreign company ‫ اﻟﺸﺨﺺ اﳌﻜﻠﻒ ﻤﺑﻬﺎﻤت ﻋﺎﻣﺔ ﻋﻠﻴﺎ ﰲ اﳌﻤﻠﻜﺔ أو دوـﻠﺔ أﺟﻨﺒﻴـﺔ‬:‫اﻟﺸﺨﺺ اﻟﺴﻴﺎﳼ اﳌﻌﺮض ﻟﻠﻤﺨﺎﻃﺮ‬

or an international organization, such as: ‫ وﻳﺸﻤﻞ ذﻟﻚ اﳌﻨﺎﺻﺐ أو اﻟﻮﻇﺎﺋﻒ اﻟﺘﺎﻟﻴﺔ‬،‫أو ﻣﻨﺎﺻﺐ إدارﻳﺔ ﻋﻠﻴﺎ أووﻇﻴﻔﺔ ﰲ إﺣﺪى اﳌﻨﻈﺎﻤت اﻟﺪوﻟﻴﺔ‬

a) Presidents of states or governments, senior politicians, government officials, judicial or military ‫ وﻛﺒـﺎر‬،‫ وﻛﺒﺎر اﻟﺴﻴﺎﺳﻴﻦﻴ أواﳌﺴﺆوﻟﻦﻴ اﻟﺤﻜﻮﻣﻴﻦﻴ أو اﻟﻘﻀﺎﺋﻴﻦﻴ أو اﻟﻌﺴﻜﺮﻳﻦﻴ‬،‫ رؤﺳﺎء اﻟﺪول أو اﻟﺤﻜﻮﻣﺎت‬-‫أ‬

officials, senior executives of countries-owner corporations, senior officials of political parties. .‫ واﳌﺴﺆوﻟﻮن اﻟﺒــﺎرزون ﰲ اﻷﺣـﺰاب اﻟﺴﻴﺎﺳﻴـﺔ‬،‫اﳌﺴﺆوﻟﻦﻴ اﻟﺘﻨﻔﻴﺬﻳﻦﻴ ﰲ اﻟﴩﻛـﺎت اﻟﺘﻲ ﻤﺗﻠﻜﻬـﺎ اﻟـﺪول‬

b) Presidents and directors of international organizations and their deputies and members of .‫ أوأي وﻇﻴﻔﺔ ﻣﺎﻤﺛﻠﺔ‬،‫ رؤﺳﺎء و ﻣﺪﻳﺮ واﳌﻨﻈﺎﻤت اﻟﺪوﻟﻴﺔ وﻧﻮاﺑﻬﻢ وأﻋﻀﺎء ﻣﺠﻠﺲ اﻹدارة‬-‫ب‬

the board of directors, or any similar position.

Additional Benefits* *‫ﺗﻐﻄﻴﺎت إﺿﺎﻓﻴﺔ‬

Please tick ( √ ) if yes in the appropriate box.
Agency (latest 5 years model only) (‫ ﺳﻨﻮات‬٥ ‫وﻛﺎﻟﺔ )ﻣﻮدﻳﻞ آﺧﺮ‬
Dealer repair: :‫إﺻﻼح اﻟﺴﻴﺎرة ﻟﺪى‬
Workshop ‫ورﺷﺔ‬

Personal Accident Benefit for Driver (Death and physical injuries and medical expenses for the Driver or Named Driver.) ‫(اﻟﻮﻓﺎة واﻹﺻﺎﺑﺔ اﻟﺠﺴﺪﻳﺔ واﳌﺼﺎرﻳﻒ اﻟﻄﺒﻴﺔ ﻟﻠﺴﺎﺋﻖ أو اﻟﺴﺎﺋﻖ اﳌﺴﻤﻰ‬ ‫ﺗﻐﻄﻴﺔ اﻟﺤﻮادث اﻟﺸﺨﺼﻴﺔ ﻟﻠﺴﺎﺋﻖ‬
Road assistance cover ‫ﺗﻐﻄﻴﺔ ﺧﺪﻣﺔ اﳌﺴﺎﻧﺪة ﻋﲆ اﻟﻄﺮﻳﻖ‬
Compensation of Rental Car Facility at the time of accident ‫ﺗﻌﻮﻳﺾ ﻋﻦ إﺟﺎر ﺳﻴﺎرة ﺑﺪﻳﻠﺔ وﻗﺖ اﻟﺤﺎدث ﻓﻘﻂ‬
(maximum of rental cost of 150 SAR per day and up to 15 days)
Unnamed drivers addition (any driver holding a drivers license) ‫ ﻳﻮم ﻓﻘﻂ‬15 ‫ رﻳﺎل ﰲ اﻟﻴﻮم و ﳌﺪة‬١٥٠ ‫ﺗﺄﺟﻴﺮ اﻟﺴﻴﺎرة اﻟﺒﺪﻳﻠﺔ ﺑﺤﺪ أﻋﲆ‬
Geographical extension ‫) ﺗﻐﻄﻴﺔ اﻟﺴﺎﺋﻘﻦﻴ اﻟﻐﺮﻴ ﻣﺴﻤﻴﻦﻴ ( اي ﺳﺎﺋﻖ ﻳﺤﻤﻞ رﺧﺼﺔ ﻗﻴﺎدة‬

‫ﺗﻐﻄﻴﺔ ﺟﻐﺮاﻓﻴﺔ‬

Other ‫أﺧﺮى‬ Bahrain ‫اﻟﺒﺤﺮﻳﻦ‬ Jordan ‫اﻷردن‬ GCC ‫دولاﻟﺨﻠﻴﺞ‬

Period of insurance: :‫ﻣﺪة اﻟﺘﺄﻣﻦﻴ‬

From: :‫إﱃ‬ To: :‫ﻣﻦ‬
Both dates ‫ﺷﺎﻣﻠﺔ ﻛﻼ اﻟﺘﺎرﻳﺨﻦﻴ‬

VAT No. 300189677400003 ‫اﻟﺮﻗﻢ اﻟﴬﻳﺒﻲ‬

U.No. 920003655 ‫اﻟﺮﻗﻢ اﳌﻮﺣﺪ‬

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Vehicle information #1* *١# ‫ﺑﻴﺎﻧﺎت اﳌﺮﻛﺒﺔ‬
‫اﻟﻘﻴـﻤﺔ اﻟﺘﺄﻣﻴﻨﻴﺔ‬ ‫رﻗﻢ اﻟﻬﻴﻜﻞ‬ ‫ﻣﻮدﻳﻞ اﳌﺮﻛﺒﺔ‬ ‫ﻃﺮاز اﳌﺮﻛﺒﺔ‬ ‫ﻣﺎرﻛﺔ اﳌﺮﻛﺒﺔ‬
Vehicles Sum Insured Chassis No. Year of Manufacture Vehicle Model Vehicle Make

‫ اﻟﺠﻤﺮﻲﻛ‬/‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﲇ‬ ‫اﻟﻠﻮن‬ ‫ﻋﺪد اﳌﻘﺎﻋﺪ‬ ‫رﻗﻢ اﻟﻠﻮﺣﺔ‬

Sequence No./Custom ID Color Seating Capacity Plate No

Details Of Drivers* *‫ﺗﻔﺎﺻﻴﻞ اﻟﺴﺎﺋﻘﻦﻴ‬

‫ﻧﻮع اﻟﺮﺧﺼﺔ‬ ‫اﳌﻬﻨﺔ‬ ‫اﻟـﺘـﻌـﻠﻴـــﻢ‬ ‫اﻟﺤﺎﻟﺔ اﻻﺟﺘﺎﻤﻋﻴﺔ‬ ‫اﻟﺠــﻨﺲ‬ ‫رﻗﻢ اﻟﻬﻮﻳﺔ‬ ‫اﺳﻢ اﻟﺴﺎﺋــﻖ‬
Type of Licence Job position Education Marital Status Gender ID # Driver name

* Mandatory fields ‫* ﺣﻘﻮل إﻟﺰاﻣﻴﺔ‬

Factors related to vehicle ‫ﻋﻮاﻣﻞ ذات ﺻﻠﺔ ﺑﺎﳌﺮﻛﺒﺔ‬

Current mileage ً‫اﳌﺴﺎﻓﺔ اﳌﻘﻄﻮﻋﺔ ﺣﺎﻟﻴﺎ‬

Engine size (liter or cubic centimeter) (‫ﺣﺠﻢ اﳌﺤﺮك )ﺳﻨﺘﻤﻴﱰ ﻣﻜﻌﺐ او ﺑﺎﻟﻠﱰ‬

Personal & Leisure ‫ﺷﺨﴢ وﺗﺮﻓﻴﻬﻲ‬

Purpose of vehicle usage* *‫اﻟﻐﺮض ﻣﻦ إﺳﺘﺨﺪام اﳌﺮﻛﺒﺔ‬
Personal & Leisure and from/to work ‫ﺷﺨﴢ وﺗﺮﻓﻴﻬﻲ ﻣﻦ وإﱃ اﻟﻌﻤﻞ‬
Private driver ‫ﺳﺎﺋﻖ ﺷﺨﴢ‬
Uber or similar ‫أوﺑﺮ أو ﺧﺪﻣﺔ ﻣﺸﺎﺑﻬﺔ‬
Taxi driver ‫ﺳﺎﺋﻖ أﺟﺮة ﻣﺮﺧﺺ‬

Transmission* Automatic ‫أوﺗﻮﻣﺎﺗﻴﻲﻜ‬ Manual ‫ﻳﺪوي‬ *‫ﻧﺎﻗﻞ اﻟﺤﺮﻛﺔ‬

Vehicle parking ‫ﻣﻜﺎن إﻳﻘﺎف اﳌﺮﻛﺒﺔ‬
Garage ‫اﳌﺮآب‬ Home Lane ‫اﳌﻤﺮ اﳌﺆدي ﻟﻠﻤﻨﺰل‬ Street ‫اﻟﺸﺎرع‬
at night* *‫أﺛﻨﺎء اﻟﻠﻴﻞ‬
Economic total loss ‫ﻧﺴﺒﺔ اﻟﻬﻼك اﻟﻜﲇ‬
% ‫اﻻﻗﺘﺼﺎدي‬
Percentage

* Mandatory fields ‫* ﺣﻘﻮل إﻟﺰاﻣﻴﺔ‬

Burglar alarm system Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﺟﻬﺎز اﻹﻧﺬار ﺿﺪ اﻟﴪﻗﺔ‬

ABS break Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻧﻈﺎم ﻣﻜﺎﺑﺢ ﻣﺎﻧﻊ اﻷﻧﺰﻻق‬
Automatic breaks Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻧﻈﺎم ﻣﻜﺎﺑﺢ أوﺗﻮﻣﺎﺗﻴﻲﻜ‬
(to avoid inevitable accidents or reduce accident damage) ( ‫) ﳌﻨﻊ وﻗﻮع اﻹﺻﻄﺪام اﻟﻮﺷﻴﻚ أو اﻟﺤﺪ ﻣﻦ آﺛﺎره‬
Cruise control Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻣﺜﺒﺖ اﻟﴪﻋﺔ‬
Adaptive cruise control Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻣﺜﺒﺖ اﻟﴪﻋﺔ اﻟﺘﻜﻴﻔﻲ‬
Rear sensors for parking Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫اﻟﺤﺴﺎﺳﺎت اﻟﺨﻠﻔﻴﺔ ﻟﻠﻤﻮاﻗﻒ‬
Front sensors Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫اﻟﺤﺴﺎﺳﺎت اﻷﻣﺎﻣﻴﺔ‬
Rear camera Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫اﻟﻜﺎﻣﺮﻴا اﻟﺨﻠﻔﻴﺔ‬
Front camera Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫اﻟﻜﺎﻣﺮﻴا اﻷﻣﺎﻣﻴﺔ‬
360 View Camera Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ درﺟﺔ‬٣٦٠ ‫اﻟﻜﺎﻣﺮﻴا ذات اﻟـ‬
Fire extinguisher Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻃﻔﺎﻳﺔ اﻟﺤﺮﻳﻖ‬

Modifications to the vehicle Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫اﻟﺘﻌﺪﻳﻼت ﻋﲆ اﻟﺴﻴﺎرة‬

(details in case of any)* *(‫)اﻟﺘﻔﺎﺻﻴﻞ‬

VAT No. 300189677400003 ‫اﻟﺮﻗﻢ اﻟﴬﻳﺒﻲ‬

U.No. 920003655 ‫اﻟﺮﻗﻢ اﳌﻮﺣﺪ‬

2
Proposer License Information ‫ﻣﻌﻠﻮﻣﺎت اﻟﺮﺧﺼﺔ ﻟﺤﺎﻣﻞ اﻟﻮﺛﻴﻘﺔ‬

License owning years* Less than a year ‫أﻗﻞ ﻣﻦ ﺳﻨﺔ‬ *‫ﻋﺪد ﺳﻨﻮات إﻣﺘﻼك اﻟﺮﺧﺼﺔ‬
Years No. ‫ﻋﺪد اﻟﺴﻨﻦﻴ‬
Countries that policy
‫اﻟﺮﺧﺺ اﻟﺼﺎﻟﺤﺔ‬
holder has valid driving
license ‫اﻟﺼﺎدرة ﻣﻦ دول أﺧﺮى‬
Less than a year ‫أﻗﻞ ﻣﻦ ﺳﻨﺔ‬ ‫ﻋﺪد ﺳﻨﻮات إﻣﺘﻼك‬
Years of owning other
‫ﻋﺪد اﻟﺴﻨﻦﻴ‬
countries driving license Years No.
‫رﺧﺼﺔ اﻟﻘﻴﺎدة ﻟﻠﺪول اﳌﺬﻛﻮرة‬
Driving tickets such as speeding ticket, traffic light ticket, etc ‫ ﻗﻄﻊ إﺷﺎرة وﺧﻼﻓﻬﺎ‬،‫اﳌﺨﺎﻟﻔﺎت اﳌﺮورﻳﺔ ﻣﺜﻞ ﺗﺠﺎوز اﻟﴪﻋﺔ‬
0 1 2 +3
Automatic vehicle ‫ﺳﻴﺎرة أوﺗﻮﻣﺎﺗﻴﻜﻴﺔ‬ No restrictions ‫ﻻﻗﻴﻮد‬
Health status as in Prosthesis ‫ﺟﺮاﺣﺔ ﺗﺮﻗﻴﻌﻴﺔ‬ Eye glasses ‫ﻧﻈﺎرة ﻃﺒﻴﺔ‬ ‫اﻟﻈﺮوف اﻟﺼﺤﻴﺔ ﻛﺎﻤ‬
driving license Hearing aid ‫ﻣﺴﺎﻋﺪات اﻟﺴﻤﻊ‬ Day time only ‫ﺳﺎﻋﺎت اﻟﻨﻬﺎر ﻓﻘﻂ‬ ‫ﻫﻮ وارد ﰲ رﺧﺼﺔ‬
Local driving ‫اﻟﻘﻴﺎدة اﳌﺤﻠﻴﺔ‬ Handicap vehicle ‫ﻣﺮﻛﺒﺔ اﻹﻋﺎﻗﺔ‬ ‫اﻟﻘﻴﺎدة‬
Personal use ‫إﺳﺘﺨﺪام ﺷﺨﴢ‬

Number of accidents when the fault is ‫ﻋﺪد اﻟﺤﻮداث اﻟﺘﻰ ﻳﻘﻊ اﻟﺨﻄﺄ ﻓﻴﻬﺎ ﻋﲆ‬
Years eligible for a ‫اﳌﺆﻣﻦ ﻟﻪ ﰲ اﻷﻋﻮام اﻟﺨﻤﺴﺔ اﳌﺎﺿﻴﺔ‬
‫اﻟﺴﻨﻮات اﳌﺆﻫﻠﺔ‬
on the insurer in the last 5 years
discount for claims free ‫ﻟﻠﺤﺼﻮل ﻋﲆ ﺧﺼﻢ ﻋﺪم‬
Number of claims when the fault is on ‫ﻋﺪد اﳌﻄﺎﻟﺒﺎت اﻟﺘﻰ ﻳﻘﻊ اﻟﺨﻄﺄ ﻓﻴﻬﺎ ﻋﲆ‬
‫وﺟﻮد ﻣﻄﺎﻟﺒﺎت‬
the insurer in the last 5 years ‫اﳌﺆﻣﻦ ﻟﻪ ﰲ اﻷﻋﻮام اﻟﺨﻤﺴﺔ اﳌﺎﺿﻴﺔ‬

Give details of all accidents, claims or losses during the last five (5) years (whether ‫إﻋﻄﺎء ﺗﻔﺎﺻﻴﻞ ﻋﻦ ﺟﻤﻴﻊ اﻟﺤﻮادث واﳌﻄﺎﻟﺒﺎت أو اﻟﺨﺴﺎﺋﺮ ﺧﻼل اﻟﺴﻨﻮات اﻟﺨﻤﺲ اﳌﺎﺿﻴﺔ‬
at fault or not) involving any vehicles owned or insured by you or not. .‫)ﺳﻮاء ﻛﺎن ذﻟﻚ ﺧﻄﺄ أو ﻻ( اﻟﺘﻲ ﺗﻨﻄﻮي ﻋﲆ أﻳﺔ ﻣﺮﻛﺒﺎت ﻣﻤﻠﻮﻛﺔ أو ﻣﺆﻣﻨﺔ ﻣﻦ ﻗﺒﻠﻚ أم ﻻ‬

* Mandatory fields ‫* ﺣﻘﻮل إﻟﺰاﻣﻴﺔ‬

Other Details* *‫ﺗﻔﺎﺻﻴﻞ أﺧﺮى‬

Have been refused motor Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻫﻞ ﺣﺪث ﰱ وﻗﺖ ﻣﻦ‬
insurance at any time or ‫اﻷوﻗﺎت أن ﻗﺎﻣﺖ أي‬
subjected to special ‫ﴍﻛﺔ ﺗﺄﻣﻦﻴ ﺑﺮﻓﺾ ﻃﻠﺐ‬
conditions in a motor ‫اﻟﺘﺄﻣﻦﻴ أو ﻃﻠﺒﺖ‬
insurance policy? ‫ﴍوط ﺧﺎﺻﺔ أو زادت ﻗﺴﻂ‬
if yes, please give details ‫اﻟﺘﺄﻣﻦﻴ أو ﻋﺪم‬
‫ﺗﺠﺪﻳﺪ اﻟﻮﺛﻴﻘﺔ؟‬
‫ اﻟﺮﺟﺎء ﺗﻘﺪﻳﻢ اﻟﺘﻔﺎﺻﻴﻞ‬،‫إذا ﻧﻌﻢ‬
Have you or your named Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻫﻞ ﺗﻢ ﺻﺪور ﺣﻜﻢ ﻗﻀﺎﻲﺋ‬
drivers been convicted of
any driving offences ‫ﺑﺤﻖ أي ﻣﻦ اﻟﺴﺎﺋﻘﻦﻴ‬
in the past three years 3 ‫اﳌﺬﻛﻮرة أﺳﺎﻤﺋﻬﻢ ﰲ‬
If Yes, please give details ‫ﺳﻨﻮات اﳌﺎﺿﻴﺔ؟‬
‫ اﻟﺮﺟﺎء ﺗﻘﺪﻳﻢ اﻟﺘﻔﺎﺻﻴﻞ‬،‫إذا ﻧﻌﻢ‬

‫ﻫﻞ ﻛﺎﻧﺖ ﻫﻨﺎﻟﻚ أي ﺣﻮادث أو‬

Was there any accident or Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬
loss (either resulted in a ‫ﺧﺴﺎﺋﺮ ) ﺳﻮاء ﻧﺘﺠﺖ ﻋﻨﻬﺎ‬
claim or not) during the ‫ﻣﻄﺎﻟﺒﺔ أم ﻻ( ﺧﻼل اﻟﺴﻨﻮات‬
past three years, with ‫اﻟﺜﻼث اﳌﺎﺿﻴﺔ ﻓﻴﺎﻤ ﻳﺘﻌﻠﻖ‬
respect to any vehicle ‫ﺑﺄي ﺳﻴﺎرة ﻣﻤﻠﻮﻛﺔ ﻟﻜﻢ أو‬
owned, driven or used by ‫ﺗﺤﺖ ﻗﻴﺎدﺗﻜﻢ أو ﻣﺴﺘﺨﺪﻣﺔ ﻣﻦ‬
you? leadership or used ِ
‫ﻗﺒﻠﻜﻢ؟‬
by you? ‫ اﻟﺮﺟﺎء ﺗﻘﺪﻳﻢ اﻟﺘﻔﺎﺻﻴﻞ‬،‫إذا ﻧﻌﻢ‬
If Yes, please give details

Do you have any Yes ‫ ﻧﻌﻢ‬No ‫ﻻ‬ ‫ﻫﻞ ﺗﻢ اﻟﻐﺎء أي ﺗﺄﻣﻦﻴ ﻋﲆ‬
insurance terminated in ‫ ﺷﻬﺮا ً اﳌﺎﺿﻴﺔ‬12 ‫ﻣﺪار‬
the last 12 months due to ‫ﺑﺴﺒﺐ ﻗﺼﻮر ﰲ دﻓﻊ ﻗﺴﻂ‬
breach of any premium ‫اﻟﺘﺄﻣﻦﻴ؟‬
payment conditions? ‫ اﻟﺮﺟﺎء ﺗﻘﺪﻳﻢ اﻟﺘﻔﺎﺻﻴﻞ‬،‫إذا ﻧﻌﻢ‬
If Yes, please give details
* Mandatory fields ‫* ﺣﻘﻮل إﻟﺰاﻣﻴﺔ‬

VAT No. 300189677400003 ‫اﻟﺮﻗﻢ اﻟﴬﻳﺒﻲ‬

U.No. 920003655 ‫اﻟﺮﻗﻢ اﳌﻮﺣﺪ‬

3
I/We do hereby declare that the vehicle(s) described is/are and ‫اﻟﺴﻴﺎرات ﺗﺘﻢ اﳌﺤﺎﻓﻈﺔ ﻋﻠﻴﻬﺎ وﺳﺘﻈﻞ‬/‫ﺑﻬﺬا أﻗﺮ وأﻋﻠﻦ ﺑﺄن اﻟﺴﻴﺎرة‬
shall be kept in good condition and that the answers above ‫اﳌﺤﺎﻓﻈﺔ ﻋﻠﻴﻬﺎ ﺑﺤﺎﻟﺔﺟﻴﺪة وأن اﻹﺟﺎﺑﺎت اﳌﻌﻄﺎة ﺣﻘﻴﻘﻴﺔ وﺻﺤﻴﺤﺔ ﰲ ﻛﻞ‬
given are in every respect true and correct and I/we hereby
agree that this Declaration shall be the basis of the contract of ‫ﺟﺎﻧﺐ ﻣﻨﻬﺎ وﺑﻬﺬا أﻗﺮ ﺑﺄن ﻫﺬا اﻹﻗﺮار ﺳﻴﻜﻮن اﻷﺳﺎس ﻟﻌﻘﺪ اﻟﺘﺄﻣﻦﻴ ﺑﻦﻴ اﻟﴩﻛﺔ‬
insurance between the Company and myself/ourselves. I/we ‫ ﻣﻊ ﻣﺮاﻋﺎة‬، ‫وﺑﻴﻨﻲ و أواﻓﻖ ﻋﲆ ﻗﺒﻮل وﺛﻴﻘﺔ ﺗﺄﻣﻦﻴ وﻓﻘﺎً ﻟﻄﻠﺐ اﻟﺘﺄﻣﻦﻴ أﻋﻼه‬
agree to accept a Policy of Insurance according to the above ‫اﻷﺣﻜﺎم واﻹﺳﺘﺜﻨﺎءات واﻟﴩوط اﻟﺘﻲ ﺳﺘﻮﺿﺢ ﺿﻤﻦ أو ﻋﲆ وﺛﻴﻘﺔ اﻟﺘﺄﻣﻦﻴ‬
proposal, subject to the terms, exceptions and conditions to be
. ‫وأﺗﻌﻬﺪ ﺑﺪﻓﻊ ﻗﺴﻂ اﻟﺘﺄﻣﻦﻴ ﻋﻨﺪﻣﺎ ﻳﻄﻠﺐ ﻣﻨﻲ اﻟﻘﻴﺎم ﺑﺬﻟﻚ‬
expressed in and on the Policy, and undertake to pay the
premium when called upon to do so.

I/We undertake that the car or cars to be insured shall not be ‫اﻟﺴﻴﺎرات اﻟﺘﻲ ﺳﻴﺘﻢ اﻟﺘﺄﻣﻦﻴ ﻋﻠﻴﻬﺎ ﻟﻦ ﺗﺘﻢ ﻗﻴﺎدﺗﻬﺎ‬/‫ﻛﺎﻤ أﺗﻌﻬﺪ ﺑﺄن اﻟﺴﻴﺎرة‬
driven by any person who to my/our knowledge has been ‫ﻣﻦ ﻗﺒﻞ أي ﺷﺨﺺ ﺑﺤﺴﺐ ﻋﻠﻤﻲ – ﺳﺒﻖ وأن ﺗﻢ رﻓﻀﻪ ﻣﻦ ﻗﺒﻞ أو رﻓﻀﺖ‬
refused any Motor Vehicle Insurance or continuance thereof.
. ‫إﺳﺘﻤﺮاره ﻣﻊ أي ﴍﻛﺔ ﺗﺄﻣﻦﻴ ﻋﲆ اﻟﺴﻴﺎرات‬
Signing this proposal form does not bind the proposer or
Wataniya Insurance Company to complete this insurance.
Liability of the Company does not commence until acceptance
of the Proposal has been intimated by the Company or official
cover note issued

Warning: Before signing this form be satisfied that all answers ‫ ﺗﺄﻛﺪ ﻟﻺﻗﺘﻨﺎع ﺑﺄنﺟﻤﻴﻊ اﻹﺟﺎﺑﺎت اﳌﻌﻄﺎة‬، ‫ ﻗﺒﻞ ﺗﻮﻗﻴﻊ ﻫﺬا اﻟﻨﻤﻮذج‬: ‫ﺗﺤﺬﻳﺮ‬
given are true and complete and that no material information
. ‫ﺻﺤﻴﺤﺔ وﺣﻘﻴﻘﻴﺔ وﻛﺎﻣﻠﺔ وأﻧﻪ ﻢﻟ ﻳﺘﻢ اﻹﻣﺘﻨﺎع ﻋﻦ إﻋﻄﺎء ﻣﻌﻠﻮﻣﺎتﺟﻮﻫﺮﻳﺔ‬
has been withheld.

I, the vehicle owner, acknowledge that the attached vehicle ‫أﻗﺮ أﻧﺎ ﻣﺎﻟﻚ اﳌﺮﻛﺒﺔ ﺑﺄن ﺻﻮر اﳌﺮﻛﺒﺔ اﻟﺘﻲ ﺗﻢ إرﻓﺎﻗﻬﺎ أﺛﻨﺎء ﻃﻠﺐ اﻟﺘﺄﻣﻦﻴ ﻫﻲ‬
photos during the insurance request are of my vehicle to be ‫ وﻗﺪ ﺗﻢ إﻟﺘﻘﺎﻃﻬﺎ ﺧﻼل ﻣﺪة ﻻ ﺗﺘﺠﺎوز ﺳﺎﻋﺔ واﺣﺪة‬،‫ﳌﺮﻛﺒﺘﻲ اﳌﺮاد ﺗﺄﻣﻴﻨﻬﺎ‬
insured. These photos were taken within an hour before
‫ وأﻧﻬﺎ ﻤﺗﺜﻞ ﺣﺎﻟﺔ اﳌﺮﻛﺒﺔ وﻗﺖ‬،‫ﻗﺒﻞ إرﻓﺎﻗﻬﺎ ﻤﺑﻮﻗﻊ ﴍﻛﺔ اﻟﻮﻃﻨﻴﺔ ﻟﻠﺘﺎﻣﻦﻴ‬
attaching to the website of Wataniya Insurance. They show the
condition of the vehicle upon issuing the policy. All attached ‫ ﻛﺎﻤ أن ﺟﻤﻴﻊ اﻟﺼﻮر اﻟﺘﻲ ﺗﻢ إرﻓﺎﻗﻬﺎ ﺗﻢ إﻟﺘﻘﺎﻃﻬﺎ ﰲ وﻗﺖ‬،‫إﺻﺪار اﻟﻮﺛﻴﻘﺔ‬
photos were taken at one time and in one place. .‫واﺣﺪ وﰲ ﻧﻔﺲ اﳌﻜﺎن‬
I also acknowledge and undertake that the photos are clear
‫ﻛﺎﻤ أﻗﺮ وأﺗﻌﻬﺪ ﺑﺄن اﻟﺼﻮر اﳌﺮﻓﻘﻪ واﺿﺤﺔ وﻢﻟ ﻳﺘﻢ ﺗﻌﺪﻳﻠﻬﺎ ﺑﺄي ﺷﻜﻞ ﻣﻦ‬
and have not been modified in any way. The vehicle is intact
and clear from any impacts or damages from previous ،‫ وأن اﳌﺮﻛﺒﺔ ﺳﻠﻴﻤﺔ وﺧﺎﻟﻴﺔ ﻣﻦ أي آﺛﺎر أو ﺗﻠﻔﻴﺎت ﻟﺤﻮادث ﺳﺎﺑﻘﺔ‬،‫اﻷﺷﻜﺎل‬
accidents. The data and answers are true. The required ‫ وإﻛﺘﺎﻤل اﳌﺴﺘﻨﺪات اﳌﻄﻠﻮﺑﺔ‬،‫وأﻗﺮ وأﺗﻌﻬﺪ ﺑﺼﺤﺔ اﻟﺒﻴﺎﻧﺎت واﻷﺟﻮﺑﺔ‬
documents shown in the electronic insurance application form .‫واﳌﻮﺿﺤﺔ ﰲ ﻤﻧﻮذج ﻃﻠﺐ اﻟﺘﺄﻣﻦﻴ‬
are completed. I also acknowledge with my understanding the
following:

I hereby give Wataniya advance consent to obtain my and/or ‫أﻗﺮ ﻤﺑﻮاﻓﻘﺘﻲ ﻋﲆ ﻗﻴﺎم اﻟﴩﻛﺔ )اﻟﻮﻃﻨﻴﺔ( ﺑﺎﻻﻃﻼع ﻋﲆ اﻟﺒﻴﺎﻧﺎت اﳌﻮﺟﻮدة‬
my dependents information from the National Information ‫ﰲ ﻣﺮﻛﺰ اﳌﻌﻠﻮﻣﺎت اﻟﻮﻃﻨﻲ ﺗﺤﺖ رﻗﻢ اﻟﺴﺠﻞ اﳌﺪﻲﻧ اﻟﺨﺎص ﻲﺑ أو أﻳﺔ‬
Center. .‫ﻣﻌﻠﻮﻣﺎتﺗﺘﻌﻠﻖﺑﺎﳌﺮﻛﺒﺎتاﻟﺘﻲاﻣﺘﻠﻜﻬﺎ‬

Authorized Signature of Applicant:..................................................................... .....................................................................................:‫ﺗﻮﻗﻴﻊ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻦﻴ اﳌﻔﻮض‬

Name:............................................................................................................................ ................................................................................................................................:‫إﺳﻤﻪ‬

Date: / / / / .:‫اﻟﺘﺎرﻳﺦ‬

It is specially stipulated that any particulars given or statements ‫إن ﺗﻮﻗﻴﻊ ﻃﻠﺐ اﻟﺘﺄﻣﻦﻴ ﻫﻨﺎ ﻟﻦ ﻳﻠﺰم ﻣﻘﺪم ﻃﻠﺐ اﻟﺘﺄﻣﻦﻴ أو اﻟﴩﻛﺔ اﻟﻮﻃﻨﻴﺔ‬
made herein shall not be subject to alteration, amendment, ‫ ﻟﻦ ﺗﺒﺪأ ﻣﺴﺌﻮﻟﻴﺔ اﻟﴩﻛﺔ إﱃ أن ﻳﺘﻢ إﻋﻼن‬. ‫ﻟﻠﺘﺄﻣﻦﻴ ﺑﺈﺳﺘﻜﺎﻤل ﻫﺬا اﻟﺘﺄﻣﻦﻴ‬
variation or qualification by reason of any verbal or written
‫ﻗﺒﻮل ﻃﻠﺐ اﻟﺘﺄﻣﻦﻴ ﻣﻦ ﻗﺒﻞ اﻟﴩﻛﺔ أو ﻳﺘﻢ إﺻﺪار ﻋﻘﺪ ﺗﺄﻣﻦﻴ رﺳﻤﻲ ﺑﻌﺪ‬
statement made by Proposer or his or her agent to the
Company or any of its agents except as may be agreed to by the .‫ﻣﻌﺎﻳﻨﺔ اﻟﺴﻴﺎرة‬
Company and endorsed on the policy to be issued as hereunder.

VAT No. 300189677400003 ‫اﻟﺮﻗﻢ اﻟﴬﻳﺒﻲ‬

U.No. 920003655 ‫اﻟﺮﻗﻢ اﳌﻮﺣﺪ‬