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Motor Perfect
Proposal Form
1. The Proposer and main driver
First Name:

Mr . Mr s . Mi s s
Middle Name:

Last Name:
Marital Status:* S M D 1/V Nationality: Date of Birth:
Occupation:

Employer: P 0. Box:
ID / lqama Number:

KSA/City:
Mobile No.:

Landline No.: Fax:
Address: Email:

**Single, Married, Divorced, Widowed
Please provide details of other drivers if the vehicle will be driven by persons other than the proposer above
Name Date of Birth Nationality
Years of Driving
Experience
Years of
No Claim



Details of the vehicle owner if different from the proposer above:
Full Name: ID / lqama No.:
2. Driver History
Years of Driving Experience in Home Country In the KSA
Number of consecutive years without a claim at fault till date Proof available? Y e s N o
Please provide details of previous Insurance Company
Period Insurance Company Country Policy Number Cl ai ms Yes No


Please provide more details of past claims at fault:
Date Total Cost




Total Number of claims Total Cost of Claims
3. Vehicle Information
Make Model Type Engine CC Seats Year of Make
1+

Colour Chassis Number Plate Number Custom ID Number

Registration Expiry Date Registration Type Vehicle use Convertible?

Yes U No U
Any modification on the vehicle? Yes No If Yes, please specify:
Current Value: SAR