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
4-3
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
4-4
