Proposal Form Motor Insurance To be filled by the Proposer or his/her legal representative. Please complete all fields either on interactive form and click the submit button, or print and write in black ink and in BLOCK LETTERS and submit to [email protected] or contact our quotations team on 800 1642. We recommend to retain a copy of the completed form and any correspondence with us as a reference. 1. Client Details First Name Mobile # Middle Name Email ID Last Name Family name Driving License Details Date of Birth d d / m m / y y y y Place of Issue P.O. Box # Date of Issue d d / m m / y y y y City / Emirate License # 2. Vehicle Details Make Plate # Model Chassis # Type of Body Sedan / Coupé / SUV / Pick-up / etc Engine # Year of Make Category Private Commercial 4 6 8 Colour Engine size (cylinders) Other (specify) Seating Capacity Driver + total passenger seats Vehicle specs GCC Non-GCC Modified Current Value AED Financed by 3. Cover Details Insurance from d d / m m / 2 0 y y Third Party Liability (TPL), or to d d / m m / 2 0 y y Loss, damage & Third Party Liability (Comprehensive) 4. Insurance Conditions 4.1 The insurance cover shall include the accident occurring to: YES NO 4.1.1 The insured and family members 4.1.2 The driver at the time of the accident 4.1.3 The driver working for the insured 4.2 The insurance cover shall include damage to the motor vehicle or any part thereof during loading/unloading of the motor vehicle 4.3 Repairs of insured’s vehicle to be carried out in accordance with terms & condition of section one (1) of the policy at dealer’s workshop 4.4 Determine the name of the driver exclusively permitted to drive the insured vehicle against obtaining a discount in the insurance premium 4.5 Cover the insured vehicle outside the public road as per the concept of definition of public road as any passage open to public 5. Declaration I hereby declare that I have read the insurance policy with its terms, conditions and exclusions and that all the details supplied in this proposal form are correct and have been completed by me and/or with my knowledge and the signature placed on this form is mine/of legal representative or has been electronically submitted by me or on my behalf. I understand, that in the event of any untrue / inaccurate / mismatching / incomplete information having formed the basis of underwriting and issuance of any Quotation and subsequently the Insurance Policy, then Oman Insurance Company, at its sole discretion, shall retain the full right to reject any claim(s) submitted under such issued Policy and/or treat the Policy, or any section of it, as voidable. Signature of the Insured Completed on d d / m m / 2 0 y y For office use only: Producer Name Processed on d d / m m / 2 0 y y Oman Insurance Company (P.S.C.), Paid up Capital 461,872,125, C.R. No. 41952, Insurance Authority No. 9 dated 24/12/1984 Head Office: P.O. Box 5209, Dubai, United Arab Emirates. Tel.: 800 4746, Fax: +971 4 233 7775, www.tameen.ae
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Proposal Form Motor Insurance To be filled by the Proposer or his/her legal representative. Please complete all fields either on interactive form and click the submit button, or print and write in black ink and in BLOCK LETTERS and submit to [email protected] or contact our quotations team on 800 1642. We recommend to retain a copy of the completed form and any correspondence with us as a reference.
1. Client DetailsFirst Name Mobile # Middle Name Email ID Last Name Family name Driving License DetailsDate of Birth d d / m m / y y y y Place of Issue P.O. Box # Date of Issue d d / m m / y y y y City / Emirate License #
2. Vehicle DetailsMake Plate # Model Chassis # Type of Body Sedan / Coupé / SUV / Pick-up / etc Engine # Year of Make Category Private Commercial
4 6 8Colour Engine size (cylinders) Other (specify)Seating Capacity Driver + total passenger seats Vehicle specs GCC Non-GCC Modified
Current Value AED Financed by
3. Cover Details Insurance from d d / m m / 2 0 y y Third Party Liability (TPL), or to d d / m m / 2 0 y y Loss, damage & Third Party Liability (Comprehensive)
4. Insurance Conditions4.1 The insurance cover shall include the accident occurring to: YES NO
4.1.1 The insured and family members 4.1.2 The driver at the time of the accident 4.1.3 The driver working for the insured
4.2 The insurance cover shall include damage to the motor vehicle or any part thereof during loading/unloading of the motor vehicle 4.3 Repairs of insured’s vehicle to be carried out in accordance with terms & condition of section one (1) of the policy at dealer’s workshop
4.4 Determine the name of the driver exclusively permitted to drive the insured vehicle against obtaining a discount in the insurance premium
4.5 Cover the insured vehicle outside the public road as per the concept of definition of public road as any passage open to public
5. DeclarationI hereby declare that I have read the insurance policy with its terms, conditions and exclusions and that all the details supplied in this proposal form are correct and have been completed by me and/or with my knowledge and the signature placed on this form is mine/of legal representative or has been electronically submitted by me or on my behalf. I understand,that in the event of any untrue / inaccurate / mismatching / incomplete information having formed the basis of underwriting and issuance of any Quotation and subsequently the Insurance Policy, then Oman Insurance Company, at its sole discretion, shall retain the full right to reject any claim(s) submitted under such issued Policy and/or treat the Policy, or any section of it, as voidable.
Signature of the Insured Completed on d d / m m / 2 0 y y
For office use only:
Producer Name Processed on d d / m m / 2 0 y y
Oman Insurance Company (P.S.C.), Paid up Capital 461,872,125, C.R. No. 41952, Insurance Authority No. 9 dated 24/12/1984 Head Office: P.O. Box 5209, Dubai, United Arab Emirates. Tel.: 800 4746, Fax: +971 4 233 7775, www.tameen.ae
Submit: Print: 1: 1 First Name: 0:
2 Middle Name: 3 Family Name: 4: 1 BoD: 0:
2 BoD: 3 BoD: 4 BoD: 5 BoD: 6 BoD: 7 BoD: 8 BoD:
5 PO Box: 7 Mobile Number: 8 Email ID: 9 DL Place of Issue: 10: 1 DoI: 2 DoI: 3 DoI: 4 DoI: 6 DoI: 7 DoI: 8 DoI: 5 DoI:
11 DL Number: 6 City / Emirate:
2: 0 Make: 1 Model: 2 Type of Body: 3 Year of Make: 4 Colour: 5 Seating Capacity: 6 Current Value: 6: 1 Financed by:
7 Plate #: 8 Chassis Number: 11 Engine Size: 0: Off1: -
12 Vehicle Specifications: Off9 Engine Number: 10 Vehicle Category: Off
3: 2 Cover Type: Off1: 1 FROM: 2 FROM: 3 FROM: 4 FROM: 5 FROM: 6 FROM: 1 TO: 2 TO: 3 TO: 4 TO: 5 TO: 6 TO:
4: 1: 1 Insurance Conditions: Off3 Insurance Conditions: Off2 Insurance Conditions: Off
2 Insurance Conditions: Off3 Insurance Conditions: Off4 Insurance Conditions: Off5 Insurance Conditions: Off
5: 2: 3: 4: 6: 5: 1:
6: 2: 3: 4: 5: 6: 1:
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