PROPOSAL FOR MOTOR VEHICLE INSURANCE
(For risk located in United Arab Emirates)
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Name of Proposer
Address
Telephone
Fax
       
Age of Insured/Driver
UAE Driving Licence Nš
Date of Issue
Date of Expiry
     
Type of Vehicle:
Registration Nš

Chassis Nš

Engine Nš Nš of cylinders Colour of vehilcle Tonnage
(Comm. Vehicle)
Type of body Use of vehicle Make of vehicle Year of Manufacture Nš of Passengers incluidinhg driver Engine Capacity
       

Insured's Estimative of Value  

      

Type of Cover requered

      Third Party required 
Comprehensive
   
Options
Personal Accident Cover for Driver
Personal Accident Cover for Passenger
Extension for Oman
Cover for Drivers below 25 years of Age
          
For driven by persons below 25 years of age.
Do you prefer to bear higher percentage of loss or pay higher premium?
       
Accident History of last 3 years
How many accidents and the total amount?
How many numbers and amount due to Third Party Fault?

Name of Previous Insurer and amount?  

Reason for change of Insurer?

I/We certify that the above information is true to the best of my/our knowledge and belief
            
Date
Place

 


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