Motor Vehicle Insurance Proposal Form   Please select the country/city where the form is to be submitted -Select Country- Kuwait Lebenon Saudi Arabia U.A.E A. General Information Insured Name (in Block Capitals) : (as will appear on the Policy) Address : Telephone No : Fax No : E-mail : Age to be Insured : Business or Profession Details of Vehicles Registration No: Driving License No: Date of Issue of Driving License: Engine No: Horse Power: Chassis No: Engine Capacity: Year of Manufacture: Use of Vehicle: Colour of Vehicle: Type of Body: No. of Passengers including Driver: Make: Insured’s Estimate Value of the Vehicle’s without accessories Insured’s Estimate Value of the Vehicle’s with accessories List of accessories inside the motor vehicle Period of Insurance: From          to       Type of Cover:   Insurance against Third Party Liability   Insurance against Loss, Damage and Third Party Liability   Conditions / Questions 1. The value of the insured vehicle shall be (amt) 2. The authorized limit of repairs in accordance with Clause (3) of Section 1 of Insurance Policy for Loss, Damage and Third Party Liability shall not exceed 3. The Company’s maximum liability against material and property damages in accordance with paragraph (b) of Clause 1 of Third Party Liability for any claim arising from one accident shall not exceed Dhs. 250, 000/- 4. The Insured shall bear the amount of out of indemnity due in accordance with the Terms and Conditions of Section 1 of this Policy.   5. The Insurance cover shall include the accidents occurring to:   (a) The Insured and his / her family members / passengers select Yes No (b) The Driver at the time of the accident  select Yes No (c) The Driver working for the Insured select Yes No 6. The insurance cover shall include damage to the Motor Vehicle or any part there of during loading / unloading of the Motor Vehicle (2). select Yes No The insurance cover shall include to the Motor Vehicle or any part thereof whilst being used as a tool of trade (3). select Yes No Declaration I, the undersigned, declare that all the details outlined in this proposal considered an integral part of the Insurance Policy are true and on my responsibility, and declare also that I have read the Insurance Policy with its Terms, Conditions and Exceptions.   [ To download the form please right click the Download button and select "Save target as" and Save.]  Download the Form           Download Acrobat Reader Top