‫ع‬.‫ع‬.‫م‬.

‫ﺗﻜﺎﻓـﻞ ﻋﻤـﺎن ﻟﻠﺘﺄﻣﻴـﻦ ش‬

Takaful Oman Insurance SAOG

1190750 :‫ رﻗﻢ اﻟﺴﺠﻞ اﻟﺘﺠﺎري‬، 24699511 968 :‫ ﻓﺎﻛﺲ‬، 22701600 968:‫ ﻫﺎﺗﻒ‬.‫ ﺳﻠﻄﻨﺔ ﻋﻤﺎن‬، 134 ‫ اﻟﺮﻣﺰ اﻟﺒﺮﻳﺪي‬، 207 ‫ب‬.‫ص‬
P.O.Box 207, Postal Code 134, Sultanate of Oman. Tel: (968) 22701600, Fax: (968) 24699511, C.R.No: 1190750

Proposal request form Schedule NO.1

1 ‫اﺳﺘﻤﺎرة ﻃﻠﺐ ﺗﺄﻣﻴﻦ اﻟﺠﺪول رﻗﻢ‬

Participant Details ‫ﺗﻔﺎﺻﻴﻞ اﻟﻤﺸﺘﺮك‬

Mr. MAKHTAR MAJAHAD MO
Name Of Participant HAMMED SULAIMAN AL BAH ‫اﺳﻢ اﻟﻤﺸﺘﺮك‬
RI
Trade Name (for Companies) : ‫اﻻﺳﻢ اﻟﺘﺠﺎري ﻟﻠﺸﺮﻛﺎت‬
CR number 25107805 ‫ رﻗﻢ اﻟﺴﺠﻞ ﻻﺗﺠﺎري‬Age 28 ‫اﻟﻌﻤﺮ‬
Date Of Birth 03/01/1995 ‫ ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬PO Box No. 112 ‫ﺻﻨﺪﻭﻕ ﺍﻟﺒﺮﻳﺪ‬
Mobile /Tel 96777214 ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬ Postal Code ‫اﻟﺮﻣﺰ ﺍﻟﺒﺮﻳﺪﻱ‬
Qualifications (Optional) (‫ﺍﻟﻤﺆﻫﻞ ﺍﻟﺪﺭﺍﺳﻲ )اﺧﺘﻴﺎري‬ Address SEEB ‫اﻟﻌﻨﻮان اﻟﺪاﺋﻢ‬
Occupation (Optional) ‫اﻟﻮﻇﻴﻔﺔ إﺧﺘﻴﺎري‬
Marital Status (Optional) (‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ )اﺧﺘﻴﺎري‬ City / Village Muscat ‫اﻟﻤﺪﻳﻨﺔ‬
Driving License No 25107805 ‫رﻗﻢ رﺧﺼﺔ اﻟﻘﻴﺎدة‬ Employer :‫ﺟﻬﺔ اﻟﻌﻤﻞ‬
License Expiry date 29/12/2023 ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ رﺧﺼﺔ اﻟﻘﻴﺎدة‬ Email ID ‫ﺍﻟﺒﺮﻳﺪ ﺍﻻﻟﻜﺘﺮﻭﻧﻲ‬
Driving License Type :‫ﻧﻮﻉ ﺮﺧﺼﺔ ﺍﻟﻘﻴﺎﺩﺓ ﻟﻠﻤﺮﻛﺒﺔ‬
Insurance cover Details ‫ﺗﻔﺎﺻﻴﻞ ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ‬
TAKAFUL OMAN INSURA
Vehicle Type SALOON :‫ ﻧﻮﻉ ﺍﻟﻤﺮﻛﺒﺔ‬Previous Insurance ‫ﺍﻟﻤﺆﻣﻨﻮﻥ ﺍﻟﺴﺎﺑﻘﻮﻥ‬
NCE
Usage/ Purpose Private ‫ﺍﻟﻐﺮﺽ ﻣﻦ ﺍﻻﺳﺘﺨﺪﺍﻡ‬
Any Modifications /additional parts on the vehicle according to law ‫ﻫﻞ ﺗﻮﺟﺪ ﺍﻱ ﺗﻌﺪﻳﻼﺕ ﺍﻭ ﺍﺿﺎﻓﺎﺕ ﻋﻠﻰ ﺍﻟﻤﺮﻛﺑﺔ ﻭﻓﻘﺎ ﻟﻠﻘﺎﻧﻮﻥ؟‬

YES / ‫ﻧﻌﻢ‬ NO / ‫ﻻ‬

Please Mention the Modification /additional Parts with estimate value ‫ﻳﺮﺟﻲ ذﻛﺮ اي ﺗﻌﺪﻳﻼت او اﺿﺎﻓﺎت ﻋﻠﻰ اﻟﻤﺮﻛﺒﺔ ﻣﻊ ذﻛﺮ اﻻﺳﻌﺎر‬
RO ‫ع‬.‫ ر‬.
RO ‫ع‬.‫ ر‬.
RO ‫ع‬.‫ ر‬.
Authorized Drivers Name ‫ﻋﺪد اﻷﺷﺨﺎص اﻟﻤﺼﺮح ﻟﻬﻢ ﻗﻴﺎدة اﻟﻤﺮﻛﺒﺔ‬
Relationship ID No. Gender Name
Age /‫اﻟﻌﻤﺮ‬
‫ﺻﻠﻪ اﻟﻘﺮاﺑﺔ‬ ‫رﻗﻢ ﺑﻄﺎﻗﺔ اﻷﺣﻮال اﻟﻤﺪﻧﻴﺔ‬ ‫اﻟﺠﻨﺲ‬ ‫اﻷﺳﻢ‬
0 Others ‫ﻣﺨﺘﺎر ﻣﺠﺎﻫﺪ اﻟﺒﺤﺮي‬
0 Others ‫ﻣﺨﺘﺎر ﺳﺎﻟﻢ اﻟﺼﻘﺮي‬
0 Brother ‫اﺳﺎﻣﻪ ﻣﺠﺎﻫﺪ اﻟﺒﺤﺮي‬
0 Others ‫ﻳﻮﺳﻒ ﺳﺎﻟﻢ اﻟﻘﺼﺮي‬
Do you have any claims which are not settled by the previous insurer? ‫ﻫﻞ ﺗﻮﺟﺪ ﻟﺪﻳﻚ ﺍﻱ ﻣﻄﺎﻟﺒﺎﺕ ﻟﻢ ﻳﺘﻢ ﺗﺴﻮﻳﺘﻬﺎ ﻣﻦ ﻗﺒﻞ ﺍﻟﻤﺆﻣﻦ ﻭﻣﺎﻧﻮﻋﻬﺎ ؟‬
YES /‫ﻧﻌﻢ‬ NO /‫ﻻ‬
If the answer is yes please state the claims and its date ‫إذا ﻛﺎﻧﺖ اﻷﺟﺎﺑﺔ ﺑﻨﻌﻢ أذﻛﺮﻫﺎ وﺗﺎرﻳﺦ ﺣﺪوﺛﻬﺎ‬
 Schedule NO. (2) (2)‫ﺟﺪول رﻗﻢ‬
Period and Type of Insurance Cover (Vehicle – Equipment) ‫ اﻟﻤﻌﺪة‬-‫ﻓﺘﺮة وﻧﻮع ﺗﻐﻄﻴﺔ اﻟﺘﺄﻣﻴﻦ اﻟﻤﺮﻛﺒﺔ‬
Period of cover
Type of Insurance Cover Contribution Signature Name
YES / ‫ﻧﻌﻢ‬ NO / ‫ﻻ‬
[ 02/01/2024 00:00 01/01/2025 23:59 ] ‫اﻻﺷﺘﺮاك‬ ‫اﻟﺘﻮﻗﻴﻊ‬ ‫اﻷﺳﻢ‬
‫ﻓﺘﺮة اﻟﺘﺎﻣﻴﻦ‬
Compulsory Insurance only NO / ‫ﻻ‬ 0.000 RO. / ‫ﺍﻟﺘﺄﻣﻴﻦ ﺍﻹﺟﺒﺎﺭﻱ ﻓﻘﻂ‬-1
‫ع‬.‫ر‬
Compulsory Insurance plus (select the appropriate ‫ اﻟﺘﺄﻣﻴﻦ اﻻﺟﺒﺎري‬+ ‫ﺗﻐﻄﻴﺔ ﺷﺎﻣﻠﺔ ﻋﻠﻰ اﻟﻤﺮﻛﺒﺔ اﻟﻤﺆﻣﻨﺔ‬
cover)
Personal Accident addendum .‫ﻣﻠﺤﻖ اﻟﺤﻮادث اﻟﺸﺨﺼﻴﺔ‬-
Natural calamities to vehicle’s body . ‫اﻟﻜﻮارث اﻟﻄﺒﻴﻌﻴﺔ اﻟﺘﻲ ﺗﺤﺪث ﻋﻠﻰ ﺟﺴﻢ اﻟﻤﺮﻛﺒﺔ‬-
Fire/ theft/ robbery only to vehicle’s body YES / ‫ﻧﻌﻢ‬ 39.000 RO. ‫ﺗﺄﻣﻴﻦ اﻟﺤﺮﻳﻖ واﻟﺴﺮﻗﺔ واﻟﺴﻄﻮ ﻓﻘﻂ اﻟﺘﻲ ﺗﺤﺪث ﻋﻠﻰ ج‬-
/ ‫ع‬.‫ر‬ . . ‫ﺳﻢ اﻟﻤﺮﻛﺒﺔ‬
Intentional act by third party (only when its not in
. (‫اﻟﻔﻌﻞ اﻟﻤﺘﻌﻤﺪ ﻣﻦ اﻟﻐﻴﺮ )ﻓﻲ ﺣﺎﻟﺔ ﻋﺪم اﻹﺳﺘﻌﻤﺎل ﻓﻘﻂ‬-
use)
Civil liability towards third parties during operation or ‫اﻟﻤﺴﺆوﻟﻴﺔ اﻟﻤﺪﻧﻴﺔ اﻟﺘﻲ ﺗﻘﻊ ﻋﻠﻰ اﻟﻐﻴﺮ ﻓﻲ أﺛﻨﺎء اﻟﺘﺸﻐﻴﻞ أو‬
at work site . ‫ﻓﻲ ﻣﻮﻗﻊ اﻟﻌﻤﻞ‬
Comprehensive Insurance covering: Compulsory NO / ‫ﻻ‬ -: ‫اﻟﺘﺄﻣﻴﻦ اﻟﺸﺎﻣﻞ وﻳﻐﻄﻲ ﻣﺎ ﻳﺄﺗﻲ‬-3
Insurance.
Damage and loss except work site. NO / ‫ﻻ‬ . ‫اﻟﺘﺄﻣﻴﻦ اﻹﺟﺒﺎري‬
Personal accidents addendum Please check NO / ‫ﻻ‬ . ‫اﻟﻔﻘﺪ واﻟﺘﻠﻒ ﻋﺪا ﻣﻮﻗﻊ اﻟﻌﻤﻞ‬
appropriate cover
Damage and loss at work site NO / ‫ﻻ‬ 0.000 RO. / .‫ﻣﻠﺤﻖ اﻟﺤﻮادث اﻟﺸﺨﺼﻴﺔ‬
‫ع‬.‫ر‬
Civil liability towards third parties during operation or NO / ‫ﻻ‬ - :( ‫)ﻳﺮﺟﻰ إﺧﺘﻴﺎر اﻟﺘﻐﻄﻴﺎت اﻟﻤﻨﺎﺳﺒﺔ‬
at work site
‫اﻟﻔﻘﺪ واﻟﺘﻠﻒ ﻓﻲ ﻣﻮﻗﻊ اﻟﻌﻤﻞ‬
‫اﻟﻤﺴﺆوﻟﻴﺔ اﻟﻤﺪﻧﻴﺔ اﻟﺘﻲ ﺗﻘﻊ ﻋﻠﻰ اﻟﻐﻴﺮ ﻓﻲ أﺛﻨﺎء اﻟﺘﺸﻐﻴﻞ أو‬
. ‫ﻓﻲ ﻣﻮﻗﻊ اﻟﻌﻤﻞ‬
39.000 RO.
Total ‫اﻹﺟﻤﺎﻟﻲ‬
/ ‫ع‬.‫ر‬

Schedule NO. (3) (3)‫ﺟﺪول رﻗﻢ‬

Additional Benefits ‫اﻟﻤﺰاﻳﺎ اﻻﺿﺎﻓﻴﺔ‬
Additional Insurance Covers YES / ‫ﻧﻌﻢ‬ NO / ‫ﻻ‬ Contribution Signature ‫ﺗﻐﻄﻴﺎت ﺗﺄﻣﻨﻴﺔ إﺿﺎﻓﻴﺔ‬
‫اﻻﺷﺘﺮاك‬ ‫اﻟﺘﻮﻗﻴﻊ‬
Change of spare parts with new original parts ‫إﺳﺘﺒﺪال ﻗﻄﻊ اﻟﻐﻴﺎر اﻟﻤﺘﻀﺮرة ﻣﻦ اﻟﺤﺎدث ﺑﺄﺧﺮى ﺟﺪﻳﺪة‬-1
after first year without paying depreciation on new NO / ‫ﻻ‬ RO. / ‫ع‬.‫ر‬ ‫اﺻﻠﻴﺔ ﺑﻌﺪ اﻟﺴﻨﺔ اﻻوﻟﻰ دون دﻓﻊ إﺳﺘﻬﻼك ﻋﻠﻰ اﻟﻘﻄﻊ اﻟﺠﺪي‬
parts. .‫د‬
Repair at agency with new original parts after first 0.000 RO. / ‫اﻹﺻﻼح ﻓﻲ اﻟﻮﻛﺎﻟﺔ اﻟﻤﻌﻨﻴﺔ وﺑﻘﻄﻊ ﻏﻴﺎر ﺟﺪﻳﺪة أﺻﻠﻴﺔ ﺑﻌﺪ ا‬-2
NO / ‫ﻻ‬
year without payment of additional amounts. ‫ع‬.‫ر‬ .‫ﻟﺴﻨﺔ اﻻوﻟﻰ ﺑﺪون دﻓﻊ أي ﻣﺒﺎﻟﻎ إﺿﺎﻓﻴﺔ‬
0.000 RO. /
No payment of excess NO / ‫ﻻ‬ .‫ﺑﺪﻭﻥ ﺩﻓﻊ ﺃﻱ ﺗﺤﻤﻞ‬-3
‫ع‬.‫ر‬
Vehicle transportation service with no distance 2.000 RO. /
YES / ‫ﻧﻌﻢ‬ . ‫ﺧﺪﻣﺔ ﻧﻘﻞ اﻟﻤﺮﻛﺒﺔ ﺑﺪون ﺗﺤﺪﻳﺪ اﻟﻤﺴﺎﻓﺔ‬-4
limit ‫ع‬.‫ر‬
0.000 RO. /
Substitute vehicle throughout repair term NO / ‫ﻻ‬ .‫ﻣﺮﻛﺒﺔ ﺑﺪﻳﻠﺔ ﻃﻮال ﻓﺘﺮة إﺻﻼح اﻟﻤﺮﻛﺒﺔ‬-5
‫ع‬.‫ر‬
Insured’s properties outside the vehicle NO / ‫ﻻ‬ RO. / ‫ع‬.‫ر‬ .‫ﻣﻤﺘﻠﻜﺎت اﻟﻤﺆﻣﻦ ﻟﻪ ﺧﺎرج اﻟﻤﺮﻛﺒﺔ‬-6
Cash compensation for consequential loss at RO ‫رﻳﺎل ع‬...... ‫اﻟﺘﻌﻮﻳﺾ اﻟﻨﻘﺪي ﻋﻦ اﻟﺨﺴﺎرة اﻟﺘﺒﻌﻴﺔ ﺑﻤﻘﺪار‬-7
NO / ‫ﻻ‬ RO. / ‫ع‬.‫ر‬
for each day of stoppage. .‫ﻣﺎﻧﻲ ﻋﻦ ﻛﻞ ﻳﻮم ﺗﻌﻄﻞ‬
Automatic renewal where there is no claim YES / ‫ﻧﻌﻢ‬ RO. / ‫ع‬.‫ر‬ .‫اﻟﺘﺠﺪﻳﺪ اﻟﺘﻠﻘﺎﺋﻲ ﻓﻲ ﺣﺎﻟﺔ ﻋﺪم وﺟﻮد ﻣﻄﺎﻟﺒﺔ‬-8
Damage, loss and third party liability for
‫ﺗﻐﻄﻴﺔ اﻟﻔﻘﺪ واﻟﺘﻠﻒ وﻣﺴﺆوﻟﻴﺔ اﻟﻄﺮف اﻟﺜﺎﻟﺚ ﻟﻠﻤﺮﻛﺒﺎت‬-9
commercial vehicles except equipment at work NO / ‫ﻻ‬ RO. / ‫ع‬.‫ر‬
. ‫اﻟﺘﺠﺎرﻳﺔ ﻋﺪا اﻟﻤﻌﺪات ﻓﻲ ﻣﻮﻗﻊ اﻟﻌﻤﻞ‬
site.
Increase transportation and protecting costs at
NO / ‫ﻻ‬ RO. / ‫ع‬.‫ر‬ ‫رﻳﺎل ﻋﻤﺎﻧﻲ‬....... ‫زﻳﺎدة ﺗﻜﺎﻟﻴﻒ اﻟﻨﻘﻞ واﻟﺤﺮاﺳﺔ ﺑﻤﻘﺪار‬-10
RO
Increase indemnity amount specified in the ‫زﻳﺎدة ﻣﺒﻠﻎ اﻟﺘﻌﻮﻳﺾ اﻟﻤﺤﺪد ﺑﻤﻠﺤﻖ اﻟﺤﻮادث اﻟﺸﺨﺼﻴﺔ إل‬-11
personal accidents addendum to RO NO / ‫ﻻ‬ RO. / ‫ع‬.‫ر‬
‫( أﻟﻒ رﻳﺎل ﻋﻤﺎﻧﻲ‬25/20/15) ‫ى‬
15,000/20,000/25,000
Any other agreed benefits. NO / ‫ﻻ‬ 0.000 RO. / ‫أي ﻣﺰاﻳﺎ أﺧﺮى ﻳﺘﻔﻖ ﻋﻠﻴﻬﺎ‬-12
‫ع‬.‫ر‬
Amount of Contribution required for additional 2.000 RO. / ‫ﻣﺒﻠﻎ اﻷﺷﺘﺮاك اﻟﻤﻄﻠﻮب ﺳﺪاده ﺑﺎﻟﻨﺴﺒﻪ ﻟﻠﻤﺰﺍﻳﺎ ﺍﻹﺿﺎﻓﻴﺔ‬
benefits ‫ع‬.‫ر‬

‫اﻟﺘﺎرﻳـﺦ‬ ‫ﺗﻮﻗﻴـﻊ ﻣﻘـﺪم اﻟﻄﻠـﺐ‬

Signature of the insurer Date Signature of the Proposer

‫ﺗﻮﻗﻴـﻊ اﻟﺆﻣﻦ‬ 27/12/2023