Motor Insurance Form

   

Name(Insured):

 *
   

CPR Number

   

Address
   

Mobile

 *
   

Email

 *
   

Fax
   

Nationality
         

Make and Model

Year of Mfg.

Registration Number

     

Color

Seating

Cubic capacity

     

Chasis Number

Engine Number

Estimate of present value (BHD)

         
   

Type of Body

Sedan Saloon Station Wagan 4 WD Convertible Coupe Others

   

Cover

Comprehensive Cover Third party only Third party fire and theft

   

Additional Personal benefit Cover

Driver Only Driver and Passengers Riot, Strike Storm,Flood
 

Hire Car KSA jurisdiction Protected No Claim Bonus Extended Agency Repairs

 

     

Please list & value any additional accessories inluded in the above value

    
           

e.g TV/Phone/Fridge

Value:

     
           
 

Value:

     
         
         
Declaration by insured (Please read carefully):

In addition to any other details supplied to the insurers I , the undersigned, also declare that all the details outlined in this proposal are an integral part of the proposed moton vehicle insurance policy and are true to the best of my knowledge and belief.