‫اﻟ ﻤ ﺠ ﻤ ﻮ ﻋ ﺔ اﻟ ﻤ ﺘ ﺤ ﺪ ة ﻟ ﻠ ﺘﺄ ﻣ ﯿ ﻦ اﻟ ﺘ ﻌﺎ وﻧ ﻲ‬

‫‪Allied Cooperative Insurance Group‬‬

‫رﻗﻢ اﻟﻮﺛﯿﻘﺔ ‪P/206/5515/19/07775247/00 :‬‬

‫أﺻ ﺪر ت ﻳﻮم ‪15/06/2019 :‬‬
‫‪Is Age Under 18:‬‬ ‫‪No‬‬ ‫ل ‪:‬ھ ﻞ اﻟ ﻌﻤﺮ ﺗﺤﺖ ‪ 18‬ﺳﻨﺔ‬ ‫ت ‪.‬اﻟ ﺴﺮﻳ ﺎن ‪16/06/2019 :‬‬
‫ت ‪.‬اﻻﻧﺘ ﮫ ﺎ ء ‪16/06/2020 :‬‬

‫)‪Motor Vehicle schedule for TPL Insurance (vehicle/s‬‬ ‫ﺟ ﺪ و ل وﺛ ﯿ ﻘ ﺔ ﺗﺄ ﻣ ﯿ ﻦ اﻟ ﻤ ﺴ ﺆ وﻟ ﯿ ﺔ اﻟ ﻤ ﺪﻧ ﯿ ﺔ ﺗ ﺠﺎ ه اﻟ ﻐ ﯿ ﺮ ) ﻣ ﺮ ﻛ ﺒﺎ ت (‬

‫‪ID / Nam e of Insured‬‬ ‫ﻋﺰﻳﺰ ﺻﺎﻟﺢ ﺑ ﻦ ا ﺣﻤﺪ ال ﻋﻄ ﯿﻪ اﻟﻐﺎﻣﺪ ي‬ ‫اﺳﻢ ‪ /‬ھﻮﻳﺔ اﻟﻤﺆﻣ ﻦ ﻟﻪ‬
‫‪Residence A ddress/ Establishment A ddress‬‬ ‫ﻋﻨ ﻮان اﻟﺴﻜﻦ‪ /‬ﻋﻨ ﻮان ﻣﻘﺮ اﻟ ﻤﻨﺸﺄة اﻟﺮﺋﯿﺴﻲ‬
‫‪District Nam e‬‬ ‫ﺣﻲ اﻟﻤ ﺸﺎﻋﺮ‬ ‫ا ﺳ ﻢ ا ﻟ ﺤﻲ‬ ‫‪Building No‬‬ ‫‪3737‬‬ ‫رﻗﻢ اﻟﻤ ﺒ ﻨﻰ‬
‫‪Unit No‬‬ ‫رﻗﻢ اﻟﻮ ﺣﺪة‬ ‫‪City‬‬ ‫ﻣﻜﺔ اﻟﻤﻜﺮﻣﺔ‬ ‫اﻟﻤﺪﻳ ﻨﺔ‬
‫‪Street Nam e‬‬ ‫ﺷﺎ رع ‪202‬‬ ‫ا ﺳ ﻢ ا ﻟ ﺸ ﺎ رع‬ ‫‪Postal Code‬‬ ‫‪24247‬‬ ‫اﻟﺮﻣﺰ اﻟ ﺒﺮﻳﺪ ي‬
‫‪Mobile No‬‬ ‫‪0566926609‬‬ ‫رﻗﻢ اﻟﺠﻮال‬ ‫‪Additional Code‬‬ ‫‪8548‬‬ ‫اﻟﺮﻗﻢ اﻹ ﺿﺎﻓﻲ‬
‫‪Customer VA T Certificate Number‬‬ ‫اﻟﺮﻗﻢ اﻟﺘﻌﺮﻳﻔﻲ ﻟﻀﺮﻳﺒ ﺔ اﻟﻘﯿ ﻤ ﺔ اﻟ ﻤﻀﺎﻓ ﺔ ﻟﻠﻌ ﻤﯿﻞ‬
‫‪Wasel A ddress‬‬ ‫ﻋﻨ ﻮان ﺑﺮﻳﺪ واﺻﻞ‬
‫‪Additional Code‬‬ ‫‪ Building No‬اﻟﺮﻗﻢ اﻹ ﺿﺎﻓﻲ‬ ‫رﻗﻢ اﻟﻤ ﺒ ﻨﻰ‬
‫‪District Nam e‬‬ ‫‪ City‬اﺳﻢ اﻟﺤﻲ‬ ‫اﻟﻤﺪﻳ ﻨﺔ‬
‫‪ Postal Code‬اﺳﻢ اﻟ ﺸﺎ رع‬ ‫اﻟﺮﻣﺰ اﻟ ﺒﺮﻳﺪ ي‬
‫‪Chassis No‬‬ ‫‪6T1BE33K76X571302‬‬ ‫رﻗﻢ اﻟ ﮫ ﯿﻜﻞ‬ ‫‪Vehicle Plate No‬‬ ‫ا ص د ‪548‬‬ ‫رﻗﻢ ﻟﻮ ﺣﺔ اﻟﻤﺮﻛ ﺒﺔ‬
‫‪Year of Manufacture‬‬ ‫‪2006‬‬ ‫ﺳ ﻨ ﺔ اﻟ ﺼ ﻨﻊ‬ ‫‪Body Type‬‬ ‫ﺳ ﯿﺎ رة ﺻﻐ ﯿﺮة ‪ 4‬ﺑﺎب‬ ‫ﻧﻮع ھ ﯿﻜﻞ اﻟﻤﺮﻛ ﺒﺔ‬
‫‪Sequence No‬‬ ‫‪173805700‬‬ ‫اﻟﺮﻗﻢ اﻟ ﺘ ﺴ ﻠ ﺴ ﻠﻲ‬ ‫‪Mak e & Model‬‬ ‫ﺗﻮﻳﻮﺗﺎ ‪ /‬ﻛﺎﻣﺮ ي‬ ‫ﻣﺎ رﻛﺔ اﻟﻤﺮﻛ ﺒﺔ و اﻟﻤﻮ دﻳﻞ‬
‫‪Seating Capacity‬‬ ‫‪5‬‬ ‫اﻟ ﺴﻌﺔ اﻹ رﻛﺎﺑ ﯿﺔ‬ ‫‪Color‬‬ ‫ا ز ر ق ﻓﺎ ﺗﺢ‬ ‫ﻟﻮ ن اﻟﻤﺮﻛ ﺒﺔ‬
‫‪Custom ID / No‬‬ ‫رﻗﻢ اﻟﺠﻤﺎ رك‬
‫ﺗﻌﺪ ھﺬه اﻟ ﻨ ﺴﺨﺔ اﻷ ﺻ ﻠ ﯿﺔ رﻗﻢ )‪ ( ١‬و ﻻ ﻳﻌ ﺘﺪ اﻻ ﺑﺄ ﺧﺮ ﻧ ﺴﺨﺔ ا ﺻ ﻠ ﯿﺔ ﻣﺨ ﺘﻮﻣﺔ و ﻣﻮﻗﻌﺔ و ﻻ ﺗﻘ ﺒﻞ اﻟ ﻨ ﺴﺦ اﻟﻤ ﺼﻮ رة أو اﻟ ﺘﻲ ﻻ ﺗﺤﻤﻞ ﺧ ﺘﻢ و ﺗﻮﻗ ﯿﻊ‬
‫‪Note that the original docum ent will be issued as num ber (1) & will only be accepted to be verified with Stam p and signed. No other‬‬
‫‪copy will be accepted unless with required Stam p & signature.‬‬
‫‪Name of the authorized drivers‬‬ ‫أﺳ ﻤﺎء اﻟﺴﺎﺋﻘﯿﻦ‬
‫ﺗﺎ رﻳﺦ اﻟﻤ ﯿﻼ د ‪DO B /‬‬ ‫رﻗﻢ اﻟ ﮫﻮﻳﺔ ‪ID /‬‬ ‫اﻻﺳﻢ ‪Nam e /‬‬
‫‪15-10-1411‬‬ ‫‪1071894149‬‬ ‫ﻋﺰﻳﺰ ﺻﺎﻟﺢ ﺑ ﻦ ا ﺣﻤﺪ ال ﻋﻄ ﯿﻪ اﻟﻐﺎﻣﺪ ي‬
‫‪Geographical lim its : The k ingdom of Saudi Arabia‬‬ ‫اﻟﺤﺪو د اﻟﺠﻐﺮاﻓ ﯿﺔ ‪ :‬اﻟﻤﻤ ﻠﻜﺔ اﻟﻌﺮﺑ ﯿﺔ اﻟ ﺴﻌﻮ دﻳﺔ‬
‫‪Lim its of liability‬‬ ‫ﺗﺤﺪﻳﺪ اﻟﻤ ﺴﺆوﻟ ﯿﺔ‬
‫‪In the event of an accident resulting in com pensation in‬‬ ‫ﻓﻲ ﺤﺎل وﻗوع ﺤﺎ دث ﯿ ﺘ ر ﺘب ﻋ ﻠ ﯿﻪ دﻓﻊ ﺘﻌو ﯿ ض وﻓﻘﺎً ﻷﺤﻛﺎم ھ ذه اﻟو ﺜ ﯿﻘﺔ ﻓﺈ ن اﻟﺤ د اﻷﻗ ﺼﻰ‬
‫‪accordance with the provisions of this docum ent, the m ax im um‬‬ ‫ﻟﻤ ﺴؤوﻟ ﯿﺔ اﻟ ﺸ رﻛﺔ ﻓﻲ اﻟواﻗﻌﺔ اﻟواﺤ دة وﺨﻼل ﻓ ﺘ رة ﺴ ر ﯿﺎ ن و ﺜ ﯿﻘﺔ اﻟ ﺘﺄﻤ ﯿ ن ﺒﺎﻟ ﻨ ﺴ ﺒﺔ ﻟﻸ ﻀ را ر‬
‫‪liability of the com pany in a single accident and during the period‬‬ ‫اﻟﺠ ﺴ د ﯿﺔ )ﺑﻤﺎ ﻓﻲ ذﻟﻚ اﻟﺪﻳﺎت و اﻟﻤ ﺒﺎﻟﻎ اﻟﻤﻘﺪ رة ﻋ ﻦ اﻹ ﺻﺎﺑﺎت و اﻟﻤ ﺼﺎ رﻳﻒ اﻟﻄ ﺒ ﯿﺔ ( واﻷ ﻀ را ر‬
‫‪of validity of the insurance docum ent for Bodily dam ages(including‬‬ ‫اﻟﻤﺎ د ﯿﺔ ﻤﻌﺎً ﻟ ن ﺘ ﺘﺠﺎو ز ﻤ ﺒ ﻠﻐ إﺠﻤﺎﻟ ﯿﺎ ﻗ د ره ‪ 10,000,000‬﷼ (ﻋ ﺸ رة ﻤﻼ ﯿ ﯿ ن ﷼‬
‫‪blood m oney and the am ounts estim ated for bodily injuries and‬‬ ‫ﺴﻌو د ي ) ﻛﺤ داً أﻗ ﺼﻰ ﻟﻤ ﺴ ﺌوﻟ ﯿﺔ اﻟ ﺸ رﻛﺔ‪.‬‬
‫‪m edical ex penses) and property dam age together would not‬‬ ‫ﻗ ﯿﻮ د اﻻﺳ ﺘﻌﻤﺎل ‪ :‬ﻳﺠﺐ ﻋ ﻠﻰ اﻟﻤﺆﻣ ﻦ ﻟﻪ أ ن ﻻ ﻳ ﺴ ﺘﻌﻤﻞ اﻟﻤﺮﻛ ﺒﺔ إﻻ ﻟ ﻠﻐﺮ ض اﻟﻤﺮ ﺧ ﺺ ﻣ ﻦ‬
‫‪ex ceed a total of 10,000,000 SR(Ten m illion riyals), the m ax im um‬‬ ‫أ ﺟ ﻠﻪ‬
‫‪liability of the com pany.‬‬ ‫ﻻ ﺗﻐﻄﻲ ھﺬه اﻟﻮﺛ ﯿﻘﺔ اﻟ ﺴ ﯿﺎ رات اﻟﻤ ﺴ ﺘﺄ ﺟﺮة ‪ ،‬و ﺳ ﯿﺎ رات اﻷ ﺟﺮة ‪ ،‬و ﺳ ﯿﺎ رات اﻟ ﻠ ﯿﻤﻮ زﻳ ﻦ‬
‫‪Restrictions:The vehicle should be used for the perm itted usage‬‬
‫‪only‬‬
‫‪This policy is not covering rent a car & tax i / lim ousine‬‬
‫‪Annual Contribution‬‬ ‫‪665.00 SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫‪ 665.00‬﷼‬ ‫اﻹﺷ ﺘﺮاك اﻟ ﺴ ﻨﻮ ي‬
‫‪Adm in Fees‬‬ ‫‪0.00 SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫‪ 0.00‬﷼‬ ‫اﻟﻤ ﺼﺎ رﻳﻒ اﻹ دا رﻳﺔ‬
‫‪Additional Age Contribution‬‬ ‫‪SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫﷼‬ ‫اﻟﻌﻤﺮ اﻹ ﺿﺎﻓﻲ‬
‫‪Personal Accident to Driver‬‬ ‫‪SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫﷼‬ ‫ﻣ ﻨﻔﻌﺔ اﻟﺤﻮا دث اﻟ ﺸﺨ ﺼ ﯿﺔ ﻟ ﻠ ﺴﺎﺋﻖ‬
‫‪Personal Accident to Passengers‬‬ ‫‪SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫﷼‬ ‫ﻣ ﻨﻔﻌﺔ اﻟﺤﻮا دث اﻟ ﺸﺨ ﺼ ﯿﺔ ﻟ ﻠﺮﻛﺎب‬
‫‪Additional loading (Due to‬‬ ‫‪SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫﷼‬ ‫اﻟﻘ ﺴﻂ اﻹ ﺿﺎﻓﻲ ﻧ ﺘ ﯿﺠﺔ اﻟﺤﺎ دث‬
‫)‪accidents‬‬ ‫ﺳﻌﻮ د ي‬ ‫‪ 66.50‬﷼‬ ‫)‪( % 10.00‬‬ ‫ﺧ ﺼﻢ ﻋﺪم و ﺟﻮ د ﻣﻄﺎﻟ ﺒﺎت‬
‫‪No Claim Discount‬‬ ‫) ‪(10.00 %‬‬ ‫‪66.50 SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫﷼‬ ‫)(‬ ‫ﺧ ﺼﻢ ﻟ ﻠﻮﻻء‬
‫‪Loyality Discount‬‬ ‫)(‬ ‫‪SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫﷼‬ ‫إ ﺟﻤﺎﻟﻲ اﻟ ﺘﺠﺪﻳﺪ‬
‫‪Renewal Total‬‬ ‫‪SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫ر‬ ‫اﻟ ﺨ ﺼﻢ‬
‫‪Special Discount‬‬ ‫‪SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫‪ 598.50‬ر‬ ‫اﻹ ﺟﻤﺎﻟﻲ ﺑﺪو ن اﻟ ﻀﺮﻳ ﺒﺔ‬
‫)‪Prem ium (Ex cl. VAT‬‬ ‫‪598.50 SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫‪ 29.93‬ر‬ ‫)‪(5.00‬‬ ‫ﺿﺮﻳ ﺒﺔ اﻟﻘ ﯿﻤﺔ اﻟﻤ ﻀﺎﻓﺔ‬
‫‪VAT‬‬ ‫)‪(5.00‬‬ ‫‪29.93 SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫‪ 598.50‬ر‬ ‫‪UPR VAT‬‬
‫‪UPR VAT‬‬ ‫‪598.50 SAR‬‬ ‫ﺳﻌﻮ د ي‬ ‫‪ 628.43‬ر‬ ‫اﻹ ﺟ ﻤ ﺎ ﻟ ﻲ‬
‫‪Total‬‬ ‫‪628.43 SAR‬‬
‫ﻳﻤﻜﻨﻚ ﺗﺤﺪ ﻳﺚ ﺑﯿﺎ ﻧﺎ ﺗﻚ ﻣﻦ ﺧﻠ ﻞ ز ﻳﺎرة ﻣﻮﻗﻊ أﺳﯿﺞ ا ﻟﻠﻜﺘﺮو ﻧﻲ ‪www.acig.com.sa‬‬
‫اﻟ ﻤ ﺠ ﻤ ﻮ ﻋ ﺔ اﻟ ﻤ ﺘ ﺤ ﺪ ة ﻟ ﻠ ﺘﺄ ﻣ ﯿ ﻦ اﻟ ﺘ ﻌﺎ وﻧ ﻲ‬
Allied Cooperative Insurance Group

Cash Receipt ‫ﺳﻨ ﺪ ﻗﺒ ﺾ ﻧ ﻘ ﺪ ي‬

Am ount Received from Client (Including Com m ission) 628.43 ( ‫ ﷼ ﺳﻌﻮ د ي )ﺷﺎﻣﻞ اﻟﻌﻤﻮﻟﺔ‬628.43 ‫اﺳ ﺘﻤ ﻠﺖ ﻣ ﻦ اﻟﻤﺬﻛﻮ ر أﻋﻼه ﻣ ﺒ ﻠﻎ‬
SAR ‫ ر ﺳﻌﻮ د ي‬11.97 ‫اﻟﻌﻤﻮﻟﺔ ﺑﺪو ن اﻟ ﻀﺮﻳ ﻨﺔ‬
Com m ission Ex cluding VAT 11.97 SAR ‫ﺿﺮﻳ ﺒﺔ اﻟﻘ ﯿﻤﺔ اﻟﻤ ﻀﺎﻓﺔ‬
VAT on Com m ission ‫ ر ﺳﻌﻮ د ي‬12.57 ‫إ ﺟﻤﺎﻟﻲ اﻟﻌﻤﻮﻟﺔ‬
Total Com m ission 12.57 SAR % 2 ‫اﻟ ﻨ ﺴ ﺒﺔ اﻟﻤ ﺌﻮﻳﺔ ﻟ ﻠﻌﻤﻮﻟﺔ‬
Com m ission Percentage 2% TAMEENI ‫ اﻟﻮﺳ ﯿﻂ‬/ ‫اﺳﻢ اﻟﻮﻛ ﯿﻞ‬
Brok er Nam e TAMEENI ‫رﻗﻢ ﺗ ﺴﺠ ﯿﻞ اﻟ ﻀﺮﻳ ﺒﺔ‬
Brok er VAT Registration No ‫ا ﻟﻤ ﺴ ﺘ ﻠ ﻢ‬
Recipient Signature ‫اﺳﻢ و ﺗﻮﻗ ﯿﻊ اﻟﻤﺆﻣ ﻦ ﻟﻪ‬
Insured nam e & signature City ‫ﻣﺪﻳ ﻨﺔ‬/:RIYADH Salesm an ‫اﻟ ﺒﺎﺋﻊ‬/: TAMEENI
PO S/ ‫ﻧﻘﻄﺔ اﻟ ﺒ ﯿﻊ‬: TAMEENI
7121 Al Am ir Turk i Ibn Abdula Aziz Al-Awal Road - Hiteen Dist. 13512 - 2305 ‫ ﺣﻲ ﺣﻄ ﯿ ﻦ اﻟﺮﻳﺎ ض‬- ‫ طﺮﻳﻖ اﻟﻤ ﯿﺮ ﺗﺮﻛﻲ ﺑ ﻦ ﻋ ﺒﺪاﻟﻌﺰﻳﺰ اﻟﻮل‬7121
RIYADH 13512 - 2305 Kingdom of Saudi Arabia P.O . Box 40523 11511 ‫ اﻟﺮﻳﺎ ض‬40523 ‫ب‬. ‫اﻟﻤﻤ ﻠﻜﺔ اﻟﻌﺮﺑ ﯿﺔ اﻟ ﺴﻌﻮ دﻳﺔ ص‬
Riyadh 11511 +966 11 485 2727 : ‫ھﺎﺗﻒ‬ +966 11 485 2626 : ‫ﻓﺎﻛﺲ‬
Tel : +966 11 485 2626 Fax : +966 11 485 2727 300007361200003 - ‫رﻗﻢ ﺗﺴ ﺠﯿﻞ ﺿﺮﻳﺒ ﺔ اﻟﻘﯿ ﻤ ﺔ اﻟ ﻤﻀﺎﻓ ﺔ‬
A CIG VA T Registration Number 300007361200003 ‫أﺳﯿﺞ‬
www.acig.com.sa ‫ﻳﻤﻜﻨﻚ ﺗﺤﺪ ﻳﺚ ﺑﯿﺎ ﻧﺎ ﺗﻚ ﻣﻦ ﺧﻠ ﻞ ز ﻳﺎرة ﻣﻮﻗﻊ أﺳﯿﺞ ا ﻟﻠﻜﺘﺮو ﻧﻲ‬