MARINE JETSKI INSURANCE

APPLICATION FORM

1. Proposer Details

1. Name First Name:

Last Name:

2. Nationality

3. Date of Birth (dd/mm/yyyy)

4. Company

5. Address Building: Street:

P.O.Box: City: Emirate:

6. Contact Number Mobile: Tel:

7. Email

2. Broker Details

1. Name of the Broker

2. Broker Branch

1
3. Details of the Jetski to be Insured

1. Make

2. Model

3. Year

4. Engine No.

5. Chasis or Hull No.

6. Material of Construction GRP FRP Others

7. Boat Use Private Commercial

8. Where is the Boat Moored When

Not in Use

9. Previous Insurers
(If Applicable)

Year Billed Premium Paid & O/S Claim

10. Loss Experience

A. Specify Currency
B. Last 5 Years Including Current Year
C. Please Describe Each and Every
Loss in Annexure

4. Cover Details

1. Policy Period From: To:

Third Party Liability + Personal Accident for the Driver

2. Type of Cover Third Party Liability + Personal Accident for the Driver + 1 Passenger

Third Party Liability + Personal Accident for the Driver + 2 Passengers

2
5. Declaration

I/we declare the above particulars to be true and correct and and that the jetski is in sound/seaworthy condition. I/we agree
that this shall form the basis of the contract between Oman Insurance Company P.S.C. (hereinafter referred to as “Sukoon”)
and me/us. I/we agree that any information collected or held by Sukoon (whether contained in application or obtained
otherwise) may be used or disclosed by Sukoon to its associate individuals/companies or any independent Third Parties
(within or outside UAE) for any matters related to this application, any Policy issued and to provide advice information
concerning products and services, which Sukoon believes may be of interests to the Proposer and to communicate with the
Proposer for any purposes.

Place and Proposers Name,

Date Signature and Seal