Motor Perfect

Proposal Form
1. The Proposer and main driver
First Name:
Mr. q Mrs. q Miss q
Middle Name: Last Name:
Marital Status:* S q M q D q W q
Nationality: Date of Birth:
Occupation: Employer: P. O. Box:
ID / Iqama 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 / Iqama 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? Yes q No q
Please provide details of previous Insurance Company
Period Insurance Company Country Policy Number
Claims Yes q No q
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 q No q
Any modification on the vehicle? Yes q No q If Yes, please specify:
Current Value: SAR
4. Type of Cover, Options and Premium
q Motor Perfect (Comprehensive) q Third Party
q Agency Repair q Limited Own Damage
q Personal Accident Driver & Passengers q Personal Accident Driver & Passengers
q GCC Cover q Accident & Breakdown Rescue
q Accident & Breakdown Rescue q Hire Car
q Hire Car
q Waiver of Depreciation
Period of Insurance ( Cover for 12 months to commence ) :
From Day / Month / Year To Day / Month / Year
Premium = Total SAR
5. Declaration
I hereby declare that to the best of my knowledge and belief that the above statements & particulars are true and
correct and that I have not withheld any information material to this proposal. I agree that this proposal and declaration
shall form the basis of the contract between the insurer and me.
I also undertake that the vehicle to be insured shall not be driven by any person below 21 years of age or with less than
12 months driving experience unless their names have been declared above. AXA liability does not commence until this
proposal has been accepted. We reserve the right to impose special terms or decline this proposal. Please refer to the
Policy booklet for full terms, conditions & exclusions. A specimen copy of this policy is available on request.
Signature: Print Name: Date:
6. Additional Documents Required
ID or Iqama - Vehicle Registration Card or Custom Card - Driving Licence
7. Payment Authorisation
In respect of the agreed insurance contract, I hereby confirm acceptance of the policy terms, conditions and premium
payable. My mode of payment will be: Cash q Cheque q Credit Card q
Please tick as appropriate: Master Card q Visa q American Express q
I hereby authorise AXA Cooperative Insurance to charge SAR:
Credit Card Number
Expiry
Date
Name (as it appears on your credit card): Card Holders Signature:
8. Important Notice
Non - disclosure: All facts are likely to influence our assessments, acceptance and renewal of this insurance must be
advised to us. If you fail to notify us of all relevant facts you may find that your policy will not operate fully. Furthermore,
you must not have any insurance cancelled, refused or any special conditions applied.
Purpose: It is warranted that the vehicle will not be used for any other purpose other than that for which it was intended,
it will not be used for the carraige of passengers or goods for hire or rental.
Adequacy of value of the vehicle: Please check whether the value indicated represents the correct market value of your
vehicle. Proof may be requested.
Existing Damages: The Company shall not liable for any loss or damage that exists prior to inception of insurance as
indicated
o Dent Scratch
AXA Cooperative Insurance
C.R. No. 1010271203
Toll free : 800 116 4845 , Website: www.axa-cooperative.com
Riyadh Office: P.O. Box 753, Riyadh 112421, KSA. Tel: +966 1 477 6706, Fax: +966 1 478 0418/478 6869
Jeddah Office: P.O. Box 812, Jeddah 21421, KSA, Tel: +966 2 263 5566, Fax: +966 2 263 2904
Al Khobar Office: P.O. Box 4539, Al Khobar 31952, KSA, Tel: +966 3 895 1250, Fax: +966 3 894 5035