Gulf Union Cooperative Insurance Company Saudi Public Joint Stock Company Paid up Capital Saudi Riyals 150 millions C.R. No. 2050056228 gle! Ono Gul alo a5. “ake Ryapnes Maal Bey S2se Sly gale V0" ggbatedl Jal! yobs Y0+sOTTYA ey dane olor: Private Car insurance Proposal Fam EES gE [ype of coverequred 1 fed aap Prpesere OT SE Eee FulNane 30 EMA SD ame Gender = Mobis Tea Ta Dae oR SEE sar aEas iy ‘Occupation Fae Naval Sate STO Eaveaion oa eer Serre Ofcousnes dress Numer af hdrennder 1 — {Wastes ls) ins Jon | Home areas Mead Wee AdGeSs [eb 1d He Ip | ad = [uaaing No. Bulag NOI os 5 ‘éiional Code [1 a Region Regio = i pscty oye ‘Zagl Posi Code Postal Code as SY 5 iAadlonal Code 7 PLOBOXAdSIO8S aloe Spe sal sini No Pesta Code a= Steet Gye weal gatiet } ip I ttandatory Files 7 ‘VERIGLETG)o be newod (Pease us soparaio pages 7 (i kami aaiaisaLcaieanammasathcds necessany) 2s SERIAL No TIER A ITE Brand of Venice 7 6d ‘Chassis None ERT = Si aPiate No.7 ‘Vehicle Usage Viele mae ‘Seating CapaciyT Ms dad color prota ke a 2 LETT Number of se. Curent mage Milage epee per yar TERE Ge TEE Wiaaiee a CARH T 5) SB en ‘aa ‘ecationoyenigh Tranomission pe Engine Se ~ Ag che = ard ad ree 7 Automat rang sem 7 Anil baking sa 7 “anh ar = Sis = aa = oe z Rea parking senso a Adaptive Cre cont |__“Y ris orl = oat m7 | Pac fl Front cameras. 2 cacao Fret senar (Ge sd Hd = CBEST SED ce th |p | SED I le Modticatos inthe ca rl ire exingucter |_"Y 360 dere am Spa ee) el odes Vehicle xe weight Taree ta Rae ed Sa ar Total Vatve Se sy Insured Decared Value ofthe “raloratachment ‘venice Value "ADDITIONAL EXTENSTON -Oniy the slated extension wb Dae ae covered) EFI TEES STE Sar Personal Accident Diver an Passenger ul “Cepsety (EB ep a ot IG wha aes Aaa “Tne caverage of age / Drivers between (16:21) ‘Agency Repair Coverage ‘Yeore Old 2a Taio Beier Name Dever Name = La T = I aT = ead Office : Ar-Moajil Commercial Centre Prince Mohammed Street Crosing Dhahran Street RO. Box $719, Dammam 31432, Saudi Arabia ‘Telephone : (013) 833-3544 (12 Lines) Fax: (013) 833-3517 nail: headofice@gulfimion-saudicom . (vr) arvareny saci (das 1) (+11) ATT =Tod: OLE atl Sp: a5 SHI Obs pla ALS ae peal pL Aygaudl Ayal ASL TTETY plat! VIA Gye aes sal headotica @2gutunin-eoud.com gg 80Gulf Union Cooperative Insurance Company Saudi Public Joint Stock Company Paid up Capital Saudi Riyals 150 millions CR. No, 2050056228 (ig lel Cp ol Quo alo a5 3) “Lake aga eine 265. agagaue Ja ge 10" ppd! Teal gel V0" OTA gy Goled Jane Tae Conder = ener Tee ae SRE Tawa co eatin Marl sas Maral sae | duction as air 0 or ond Numer of hien under 16 Oceapaion Occupation Nurpber of cide und 6 Ee Segoe Reside adress Reston aess Meal aed Je eae Of addres ie adds Tate Salo es Type of dng es ypeot desing ere essa Epa FN Slee [are of ers ing Sau iene Nambe of ers lng Sud ere Sri Ja ns sg dos8 8 IT TAT gd oa Name of counties lng come Name of cums hlding ceae Sipe al ak JS Spe ong aR Nombs of yeas amie afsrs Medi eosiion DL BE Ta pel ae Baraphiclexctabon Doan asd gs Please Angwet Flowing Question. BT Sa ave you of named Driver had a mol Tabranoe Poy canceled oF fad special terms mposed? STE FTI TT Sad Ie St oat ave you a any named Daver ever been daqualied Fam ving or hada trving eens suspended or revoked? ESI TS LT IGT tases lease advise dais lodged dung be procnding years Nuribr and ‘amounts? PSI TIL a SIMA DECLARATION Hereby, the undersigned gree To provide Gu union RSUrane Co) ‘wah ay infrmaton that. equres forth essblshing andlor ousting ondir administering my ‘Stour ad faciios {rerewth ad authrize tt obain and ecole any information 9¢ {eems necessary orn ‘ed for regarding me, my accounts and facies herewith, rom the ‘Saudi Creat Bueau (GINA and io ciciose and share (inclusive of Data Pooing) hat Information othe sis Company (SIMAH) i accordance wih the Membership Agreement fd Code of Conduct. fpproved oto any aer agency approved by Saud Arabian Monetary Agency (SAMA) Gis Faia GA SGT ETE BTA a HESS om ol alt sche cet Sia al ie mga sa agen gga goa pin Gan arpdeneidga fae yah S Be a Gi Eee Be neta os, sys dad fy) Sp a a BE Beale docene Tee Decaaton. Ee et the bt o my Your we ity con hate ‘statements contained in us proposal fom are ve ‘and covectand eed or have not eancsled misrepresent or ‘misstated any materia fact Thee agree thal he statements and declaration nhs proposal fom shat bee basis ofthe contract of neurance with the company and are deemed tobe Incorporated in he contact ‘we undertake ta he vehicle Wehices to be neue are mgood ROWE Ip pei ST (BaD Fah Satay : ‘ee Gee ah pa hed oe gO ale yf eet Yall a a Ae col hd AS IRD dosed oat Pay Sa A IS Bs ge ake ow hs ee SE alos conditions (Body8 Engine) iBone Iie agree to sezep the insurance subject othe terms and conditions ofthe company's poly and tat insurance ‘wllnot be i force unt the proposal ha been accoped by the Company expect othe exe of any ofl cover note which may be saved. Sa ee ies ‘Signature and Bate Appicant Nar ‘Decaminisraqured eave the insurance Pl SHG ey eid se TDigams copy ofthe owner ada eee YC form ile weigs ‘Vohical Ragivaon (stmarayCustom Release TT GT aS ee ‘Gommercial Regisation copy ie enrprate) bel Deh ge eR ghee ithe coverage for drver Between (18-21) or he dvar is nat the Louner copy of the Driving Weanse Wa Ses ae OT a dela ated sa Head Office : ALMoa}il Commercial Centre Prince Mohammed Stret Crossing Dhahran Street, RO. Box $719, Dammam 31432, Saudi Arabia Telephone: (O13) 833.3544 (12 Lines) Fax: (013) 833.3517 Enail: headofice@gulfinion-saudicom . (-v) ary-Toty s gaeota (das VY) (+14) ATYHTos Lt pal Sys a GSA Obl GyL blade pail Ld Apgaudl Rayall ASLedH TTETY pla! VIA ceye os eacoficaguiion-sudcom giyy2S0%1 aayGulf Union Cooperative Insurance Company Saud Public Joint Stock Company Paid up Capital Saudi Riyals 150 millions C.R. No. 2050056228 Agha Cal Guba! aloo! asa le ge Redline Aaya gapaee Dy gabe VO> ggbaall Sha oy Ys0s-OUTYA gy ges Jon Sy br SonpaTaNS BOS othe Company use aa Signatus and Bate ‘Wate Permian In accordance wih the rules of colecion and exchange of insurance infomation for vehicles, sued bythe Saud Arabian Monetary Author ad oter relied regulations tnd instructions, "agree to gran ihe insurance company the ight tongue rom Non Inaurance Senfaoe abou the ingurance caida forthe vehioes \ovwhich was a party, and | agree {To grant Nom insurance Serves the right to collec and exchange Inzranea dams data forthe vehicles to which Iwas pan, po inte, wih ngwrance and Reins. =e Mg eh he Dl ha tage iy Sse old sis ne pf canna ad See Saeco nteesiet ass Sao MOTOR INSURANCE PROPOSAL FORM Head Office: Al-Moall Commercial Centre Prince Mohammed Steet Crossing Dhahran Stret PO. Box 5719, Dammam 31432, Saudi Arabia ea 5) 908542) Fe: (5) 317 nail: headofica@gulfunion-saudicom (7) arvever LSS Seat Sp StI Obpelil fLS alas ae pai gs pagal yall ASLeaI! THEY pleat! OVS ye + adel (das 1Y)) (+07) ATY-ToLt # gas neadtieoguinin saud.com: gs) ay)