Medical Malpractice Practitioners Proposal Form ‫ﻃﻠﺐ ﺗﺄﻣﻴﻦ أﺧﻄﺎء ﻣﻤﺎرﺳﺔ اﻟﻤﻬﻦ اﻟﻄﺒﻴﱠﺔ‬

GENERAL DATA ‫ﺑﻴﺎﻧﺎت ﻋﺎﻣﺔ‬

1. Name of proposer in full: ً ‫ اﺳﻢ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ ﻛﺎﻣ‬.١

:‫ﻼ‬

2. Address: :‫ اﻟﻌﻨﻮان‬.٢
WASEL ADDRESS ‫ﻋﻨﻮان ﺑﺮﻳﺪ واﺻﻞ‬ OFFICE/WORK ADDRESS ‫ﻋﻨﻮان ﻣﻘﺮ اﻟﻌﻤﻞ‬
Building No. ‫رﻗﻢ اﻟﻤﺒﻨﻰ‬ *Building No ‫@رﻗﻢ اﻟﻤﺒﻨﻰ‬
Additional Code ‫ﺿﺎﻓﻲ‬º‫اﻟﺮﻣﺰ ا‬ *Region ‫@إﺳﻢ اﻟﻤﻨﻄﻘﺔ‬
Region ‫إﺳﻢ اﻟﻤﻨﻄﻘﺔ‬ *City ‫@إﺳﻢ اﻟﻤﺪﻳﻨﺔ‬
City ‫إﺳﻢ اﻟﻤﺪﻳﻨﺔ‬ *Postal Code ‫@اﻟﺮﻣﺰ اﻟﺒﺮﻳﺪي‬
Postal Code ‫اﻟﺮﻣﺰ اﻟﺒﺮﻳﺪي‬ *Additional Code ‫ﺿﺎﻓﻲ‬º‫اﻟﺮﻗﻢ ا‬
P.O.Box ‫ﺻﻨﺪوق اﻟﺒﺮﻳﺪ‬ Unit No. ‫رﻗﻢ اﻟﻮﺣﺪة‬
Phone/Mobile No. ‫اﻟﺠﻮال‬/‫اﻟﻬﺎﺗﻒ‬
َ ‫رﻗﻢ‬ Street ‫إﺳﻢ اﻟﺸﺎرع‬
District ‫إﺳﻢ اﻟﺤﻲ‬
Email ‫اﻟﺒﺮﻳﺪ اﻻاﻛﺘﺮوﻧﻲ‬
*Required fields ‫@ﺣﻘﻮل إﻟﺰاﻣﻴﺔ‬

3. a) At what medical School did the proposer graduate? ‫ أ( ﻓﻲ أي ﻛﻠﻴﺔ ﻃﺐ ﺗﺨﺮج ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ؟‬.٣

b) Year of Graduation? ‫ب( ﺳﻨﺔ اﻟﺘﺨﺮج؟‬

4. Professional Experience ‫ اﻟﺨﺒﺮة اﻟﻤﻬﻨﻴﺔ ﻓﻲ ﻣﺠﺎل اﻟﺘﺨﺼﺺ‬.٤

1. From: To: :‫إﻟﻰ‬ :‫ﻣﻦ‬ .١

2. From: To: :‫إﻟﻰ‬ :‫ﻣﻦ‬ .٢

3. From: To: :‫إﻟﻰ‬ :‫ﻣﻦ‬ .٣

5. Is the proposer duly licensed in accordance with law to ‫ﻣﺼﺮح ﻟﻪ ﺑﻤﻤﺎرﺳﺔ اﻟﻤﻬﻨﺔ وﻓﻖ اﻟﻘﺎﻧﻮن‬
‫ﱠ‬ ‫ ﻫﻞ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ‬.٥
practice at the address given under item 2? No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫؟‬٢ ‫اﻟﻤﻮﺿﺢ ﺑﺎﻟﺒﻨﺪ رﻗﻢ‬
‫ﱠ‬ ‫ﺑﺎﻟﻌﻨﻮان‬

6. Member of association? No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ ﻫﻞ أﻧﺖ ﻋﻀﻮ ﻓﻲ ﻧﻘﺎﺑﺔ أو اﺗﺤﺎد؟‬.٦

7. Period of Insurance: From: To: :‫إﻟﻰ‬ :‫ ﻣﻦ‬:‫ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ اﻟﻤﻄﻠﻮﺑﺔ‬.٧

PROFESSION ‫اﻟﻤﻬﻨﺔ‬

1. Other Medical .١
Surgeon Non-Surgeon ‫اﻟﻤﻬﻦ اﻟﻄﺒ ﱠﻴﺔ ا·ﺧﺮى‬ ‫ﻏﻴﺮ ﺟ ﱠﺮاح‬ ‫ﺟ ﱠﺮاح‬
Professions

General Practitioner Cardiology Pharmacist ‫اﻟﺼﻴﺎدﻟﺔ‬ ‫اﻟﻘﻠﺐ‬ ‫اﻟﻄﺐ اﻟﻌﺎم‬

Dentistry Orthopedic Surgery Lab Technician ‫ﻓﻨﻲ ﻣﺨﺘﺒﺮات ﻃﺒ ﱠﻴﺔ‬ ‫ﺟﺮاﺣﺔ اﻟﻌﻈﺎم‬ ‫ﻃﺐ ا·ﺳﻨﺎن‬
Internal Medicine Urology Nurse ‫ ﻣﻤﺮﺿﺔ‬/ ‫ﻣﻤﺮض‬ ‫اﻟﻤﺴﺎﻟﻚ اﻟﺒﻮﻟﻴﺔ‬ ‫اﻟﻄﺐ اﻟﺒﺎﻃﻨﻲ‬
Obstetrics/Gynecology Psychiatry X-Ray Technician ‫ﻓﻨﱢﻲ أﺷﻌﺔ‬ ‫اﻟﻄﺐ اﻟﻨﻔﺴﻲ‬ ‫اﻟﻨﺴﺎء واﻟﺘﻮﻟﻴﺪ‬
Pediatric Dermatology Dietician ‫أﺧﺼﺎﺋﻲ ﺗﻐﺬﻳﺔ‬ ‫ا·ﻣﺮاض اﻟﺠﻠﺪﻳﺔ‬ ‫ﻃﺐ ا·ﻃﻔﺎل‬
Neurology Ophthalmology Others: :‫أﺧﺮى‬ ‫ﻃﺐ اﻟﻌﻴﻮن‬ ‫ا·ﻣﺮاض اﻟﻌﺼﺒﻴﺔ‬
Anesthesia Others: :‫أﺧﺮى‬ ‫اﻟﺘﺨﺪﻳﺮ‬

2. Is the proposer, partner or assistant regularly involved in ‫ ﻫﻞ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ أو اﻟﺸﺮﻳﻚ أو اﻟﻤﺴﺎﻋﺪ ﻳﺸﺎرك ﺑﺼﻔﺔ ﻣﻨﺘﻈﻤﺔ‬.٢
first-aid service? No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ﻓﻲ ﺧﺪﻣﺎت إﺳﻌﺎﻓﺎت أوﻟﻴﺔ؟‬

3. Name(s) of partners For each partner all questions listed above. ‫ ﻳﺠﺐ اﻟﺮد ﻋﻠﻰ ﺟﻤﻴﻊ‬،‫ أﺳﻤﺎء اﻟﺸﺮﻛﺎء ﺑﺎﻟﻨﺴﺒﺔ ﻟﻜﻞ ﺷﺮﻳﻚ‬/‫ اﺳﻢ‬.٣
‫ا·ﺳﺌﻠﺔ أﻋﻼه ﻛﻞ ﻋﻠﻰ ﺣﺪة‬

4.Name(s) of qualified medical assistant(s) ‫ أﺳﻤﺎء اﻟﻤﺴﺎﻋﺪﻳﻦ اﻟﻄﺒﻴﻴﻦ اﻟﻤﺆﻫﻠﻴﻦ‬/‫ اﺳﻢ‬.٤

Solidarity Saudi Takaful Company ‫ﺷﺮﻛﺔ ﺳﻮﻟﻴﺪرﺗﻲ اﻟﺴﻌﻮدﻳﺔ ﻟﻠﺘﻜﺎﻓﻞ‬

Head Office - Phone +966 11 299 4555 Fax +966 11 299 4556 +966 11 2994556 ‫ ﻓﺎﻛﺲ‬+966 11 2994555 ‫ﻫﺎﺗﻒ‬
PO Box 85770 - Riyadh 11612 Kingdom of Saudi Arabia ‫ اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﻴﺔ اﻟﺴﻌﻮدﻳﺔ‬11612 ‫ اﻟﺮﻳﺎض‬- 85770 .‫ب‬.‫ص‬
info@solidarity.sa www.solidarity.sa info@solidarity.sa
Medical Malpractice Practitioners Proposal Form ‫ﻃﻠﺐ ﺗﺄﻣﻴﻦ أﺧﻄﺎء ﻣﻤﺎرﺳﺔ اﻟﻤﻬﻦ اﻟﻄﺒﻴﱠﺔ‬

5. Number of technicians employed ‫ ﻋﺪد اﻟﻔﻨﻴﻴﻦ اﻟﻌﺎﻣﻠﻴﻦ ﻟﺪى ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ‬.٥

6. Number of nurses employed ‫ ﻋﺪد أﻓﺮاد ﻃﺎﻗﻢ اﻟﺘﻤﺮﻳﺾ ﻟﺪى اﻟﻤﺆﻣﻦ ﻟﻪ‬.٦

7. Is the proposer under contract with or in the ‫ ﻫﻞ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ ﻣﺮﺗﺒﻂ ﺑﻌﻘﺪ أو ﺑﻌﻤﻞ ﻣﻊ أي ﻓﺮد أو‬.٧
employment of any individual, firm or cooperation? No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ﺷﺮﻛﺔ أو ﻣﺆﺳﺴﺔ؟‬
If so, please give details. ‫ﺟﺎﺑﺔ ”ﻧﻌﻢ“ وﺿﺢ ذﻟﻚ ﺗﻔﺼﻴﻼ‬º‫إن ﻛﺎﻧﺖ ا‬

8.Does the proposer own, wholly or in part, operate or ‫ ﻫــﻞ ﻃﺎﻟــﺐ اﻟﺘﺄﻣﻴــﻦ ﻳﻤﺘﻠــﻚ ﺑﺸــﻜﻞ ﻛﻠــﻲ أو ﺟﺰﺋــﻲ أو‬.٨
administer any hospital, nursing home or other Yes ‫ﻧﻌﻢ‬ ‫ ﻣﺮﻛــﺰ ﺗﻤﺮﻳــﺾ أو أي‬،‫ﻳﺸــﻐﻞ أو ﻳﺪﻳــﺮ أي ﻣﺴﺘﺸــﻔﻰ‬
No ‫ﻻ‬
institution where medical services are customarily ‫ﻣﺆﺳﺴــﺔ أﺧــﺮى ﻳﺘــﻢ ﻓﻴﻬــﺎ ﺗﻮﻓﻴــﺮ اﻟﺨﺪﻣــﺎت اﻟﻄﺒﻴــﺔ‬
rendered? Does he have any reserved beds there? ‫ﺑﺸﻜﻞ ﻋﺎدي؟ ﻫﻞ ﻳﻮﺟﺪ ﻟﺪﻳﻜﻢ أي أﺳﺮة ﻣﺤﺠﻮزة؟‬
If so, please give details including number of reserved beds. .‫ ﻳﺮﺟﻰ ﺗﻮﺿﻴﺢ ذﻟﻚ ﺑﻤﺎ ﻓﻲ ذﻟﻚ ﻋﺪد ا·ﺳﺮة اﻟﻤﺤﺠﻮزة‬،“‫ﺟﺎﺑﺔ ”ﻧﻌﻢ‬º‫إن ﻛﺎﻧﺖ ا‬

9.Does the proposer own or operate X-ray machines or laser? No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ ﻫﻞ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ ﻳﻤﺘﻠﻚ أو ﻳﺸﻐﻞ ﺟﻬﺎز أﺷﻌﺔ أو ﻟﻴﺰر؟‬.٩
If so, please give number, type and whether they are used for diagnosis or treatment or both. .‫ وإذا ﻛﺎﻧﺖ اﺳﺘﻌﻤﻠﺖ ﻟﻐﺮض اﻟﺘﺸﺨﻴﺺ أو اﻟﻌﻼج أو ﻛﻼﻫﻤﺎ‬،‫ اﻟﻨﻮع‬،‫ ُﻳﺮﺟﻰ ذﻛﺮ اﻟﺮﻗﻢ‬،“‫ﺟﺎﺑﺔ ”ﻧﻌﻢ‬º‫إذا ﻛﺎﻧﺖ ا‬

10.Number of patients per year: :‫ ﻋﺪد اﻟﻤﺮﺿﻰ ﻟﻜﻞ ﻋﺎم‬.١٠

PREVIOUS INSURANCE/PREVIOUS CLAIMS ‫ اﻟﻤﻄﺎﻟﺒﺎت اﻟﺴﺎﺑﻘﺔ‬/ ‫اﻟﺘﺄﻣﻴﻦ اﻟﺴﺎﺑﻖ‬

1. Has the proposer previously been insured? ‫ ﻫﻞ ﺳﺒﻖ ﻟﻚ اﻟﺘﺄﻣﻴﻦ ﻟﺪى أي ﺷﺮﻛﺔ ﺗﺄﻣﻴﻦ أﺧﺮى؟‬.١
If so, please specify: :‫ ﻳﺮﺟﻰ ﺗﻮﺿﻴﺢ ﻣﺎ ﻳﻠﻲ‬،“‫ﺟﺎﺑﺔ ”ﻧﻌﻢ‬º‫إذا ﻛﺎﻧﺖ ا‬

‫ﺣﺪ اﻟﺘﻌﻮﻳﺾ‬ ‫ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬ ‫اﺳﻢ ﺷﺮﻛﺔ اﻟﺘﺄﻣﻴﻦ‬

Compensation limit Policy Period Name of Insurer

2. Has a previous application been declined? ‫ ﻫﻞ ﺳﺒﻖ أن ﺗﻢ رﻓﺾ أي ﻃﻠﺐ ﺗﺄﻣﻴﻦ ﻟﻜﻢ؟‬.٢
No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬
Has a previous insurance ‫ﻫﻞ ﺷﺮﻛﺔ اﻟﺘﺄﻣﻴﻦ اﻟﺴﺎﺑﻘﺔ ﻃﻠﺒﺖ؟‬
No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬
a) required increased premium? ‫أ( زﻳﺎدة ﻗﺴﻂ اﻟﺘﺄﻣﻴﻦ؟‬
b) required special restrictions? No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ب( ﺷﺮوط و ﻗﻴﻮد ﻣﻌﻴﻨﺔ؟‬
c) been terminated/not been renewed by an insurer? No ‫ﻻ‬ Yes ‫ﻧﻌﻢ‬ ‫ ﻟﻢ ﻳﺘﻢ ﺗﺠﺪﻳﺪه ﻣﻦ ﻗﺒﻞ أي ﺷﺮﻛﺔ ﺗﺄﻣﻴﻦ؟‬/ ‫ج( ﺗﻢ إﻧﻬﺎؤه‬
If so, please give detailed infromation. .‫ وﺿﺢ ذﻟﻚ ﺑﺎﻟﺘﻔﺼﻴﻞ‬،‫ﺟﺎﺑﺔ ﺑﻨﻌﻢ‬º‫إذا ﻛﺎﻧﺖ ا‬

3. Have any claims or suits for malpractice been made against the proposer or ‫ ﻫﻞ ﺗﻮﺟﺪ أي ﻣﻄﺎﻟﺒﺎت أو دﻋﺎوى ﻗﻀﺎﺋﻴﺔ ﺟﺮاء أﺧﻄﺎء ﻣﻤﺎرﺳﺔ ﻃﺒﻴﺔ ﻣﺮﻓﻮﻋﺔ أو‬.٣
any of his partners, assitants, nurses or technicians during the past five ‫ﻣﻨﻈﻮرة ﺿﺪﻛﻢ أو أي ﻣﻦ ﺷﺮﻛﺎﺋﻜﻢ أو ﻣﺴﺎﻋﺪﻳﻜﻢ أو ﻣﻤﺮﺿﻴﻜﻢ أو ﺟﻬﺎزﻛﻢ اﻟﻔﻨﻲ‬
Years? ‫ﻧﻌﻢ‬ ‫ﺧﻼل اﻟﺴﻨﻮات اﻟﺨﻤﺲ اﻟﻤﺎﺿﻴﺔ؟‬
No ‫ﻻ‬ Yes
If so, please advice amount and background of each claim. .‫ وﺿﺢ ﻗﻴﻤﺔ ﻛﻞ ﻣﻄﺎﻟﺒﺔ وﺧﻠﻔﻴﺔ ﻋﺎﻣﺔ ﻋﻨﻬﺎ‬،“‫ﺟﺎﺑﺔ ”ﻧﻌﻢ‬º‫إذا ﻛﺎﻧﺖ ا‬

4. Is the proposer or any of his partners, assistants, nurses or technicians aware ‫ ﻫﻞ ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ أو أي ﻣﻦ ﺷﺮﻛﺎﺋﻪ أو ﻣﺴﺎﻋﺪﻳﻪ أو ﺟﻬﺎز اﻟﺘﻤﺮﻳﺾ أو اﻟﻔﻨﻲ ﻟﺪﻳﻪ‬.٤
of any circumstances or incidents which may result in a claim? ‫ﻋﻠﻰ ﻋﻠﻢ ﺑﺄي أوﺿﺎع أو ﺣﻮادث واﻟﺘﻲ ﻣﻦ ﺷﺄﻧﻬﺎ أن ﻳﺘﺮﺗﺐ ﻋﻠﻴﻬﺎ أي ﻣﻄﺎﻟﺒﺔ؟‬
If so, please give details. .‫ وﺿﺢ ذﻟﻚ ﺑﺎﻟﺘﻔﺼﻴﻞ‬،“‫ﺟﺎﺑﺔ ”ﻧﻌﻢ‬º‫إذا ﻛﺎﻧﺖ ا‬

Solidarity Saudi Takaful Company ‫ﺷﺮﻛﺔ ﺳﻮﻟﻴﺪرﺗﻲ اﻟﺴﻌﻮدﻳﺔ ﻟﻠﺘﻜﺎﻓﻞ‬

Head Office - Phone +966 11 299 4555 Fax +966 11 299 4556 +966 11 2994556 ‫ ﻓﺎﻛﺲ‬+966 11 2994555 ‫ﻫﺎﺗﻒ‬
PO Box 85770 - Riyadh 11612 Kingdom of Saudi Arabia ‫ اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﻴﺔ اﻟﺴﻌﻮدﻳﺔ‬11612 ‫ اﻟﺮﻳﺎض‬- 85770 .‫ب‬.‫ص‬
info@solidarity.sa www.solidarity.sa info@solidarity.sa
Medical Malpractice Practitioners Proposal Form ‫ﻃﻠﺐ ﺗﺄﻣﻴﻦ أﺧﻄﺎء ﻣﻤﺎرﺳﺔ اﻟﻤﻬﻦ اﻟﻄﺒﻴﱠﺔ‬

INDEMNITY REQUIRED ‫اﻟﺘﻌﻮﻳﺾ اﻟﻤﻄﻠﻮب‬

100,000 any one claim and in the aggregate during the whole policy period ‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ رﻳﺎل ﻋﻦ أي ﻣﻄﺎﻟﺒﺔ واﺣﺪة وﻓﻲ ا‬١٠٠,٠٠٠
(Nurses & Technicians only) (‫)اﻟﻤﻤﺮﺿﻴﻦ واﻟﻔﻨﻴﻴﻦ ﻓﻘﻂ‬

250,000 any one claim and in the aggregate during the whole policy period
250,000 any one claim and SR 500,000 in the aggregate during the whole policy period
250,000 any one claim and SR 1,000,000 in the aggregate during the whole policy period
500,000 any one claim and in the aggregate during the whole policy period
500,000 any one claim and SR 1,000,000 in the aggregate during the whole policy period
1,000,000 any one claim and in the aggregate during the whole policy period
* Gynecologist/Obstetrician restricted to category 5 only
‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ رﻳﺎل ﻋﻦ أي ﻣﻄﺎﻟﺒﺔ واﺣﺪة وﻓﻲ ا‬٢٥٠,٠٠٠
‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ رﻳﺎل ﻓﻲ ا‬٥٠٠,٠٠٠ ‫ رﻳﺎل ﻋﻦ أي ﻣﻄﺎﻟﺒﺔ واﺣﺪة و‬٢٥٠,٠٠٠
‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ رﻳﺎل ﻓﻲ ا‬١,٠٠٠,٠٠٠ ‫ رﻳﺎل ﻋﻦ أي ﻣﻄﺎﻟﺒﺔ واﺣﺪة و‬٢٥٠,٠٠٠
‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ رﻳﺎل ﻋﻦ أي ﻣﻄﺎﻟﺒﺔ واﺣﺪة وﻓﻲ ا‬٥٠٠,٠٠٠
‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ ﻓﻲ ا‬١,٠٠٠,٠٠٠‫ رﻳﺎل ﻋﻦ أي ﻣﻄﺎﻟﺒﺔ واﺣﺪة و‬٥٠٠,٠٠٠
‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ رﻳﺎل ﻋﻦ أي ﻣﻄﺎﻟﺒﺔ واﺣﺪة و ﻓﻲ ا‬١,٠٠٠,٠٠٠
‫@ ﻳﻘﺘﺼﺮ ﺗﺨﺼﺺ اﻟﻨﺴﺎء واﻟﻮﻻدة ﻋﻠﻰ اﻟﻔﺌﺔ اﻟﺨﺎﻣﺴﺔ ﻓﻘﻂ‬

(SR 500,000 any one claim and in the aggregate during the whole policy period) (‫ﺟﻤﺎﻟﻲ ﺧﻼل ﻛﺎﻣﻞ ﻓﺘﺮة اﻟﺘﺄﻣﻴﻦ‬º‫ رﻳﺎل ﻟﻜﻞ ﻣﻄﺎﻟﺒﺔ واﺣﺪة وﻓﻲ ا‬٥٠٠,٠٠٠)

Deductible: amount to be borne by the insured each and every claim/loss: :‫ﻣﻄﺎﻟﺒﺔ‬/‫اﻟﻤﺆﻣﻦ ﻟﻪ ﻋﻦ ﻛﻞ ﺣﺎدث‬
‫ﱠ‬ ‫ﻳﺘﺤﻤﻠﻪ‬
‫ﱠ‬ ‫ اﻟﻤﺒﻠﻎ اﻟﺬي‬:‫ﻗﺘﻄﺎع‬º‫ا‬/‫اﻟﺘﺤﻤﻞ‬

DECLARATION ‫إﻗﺮار‬

I/We declare that the statements and particulars in this proposals are true and ‫أﻗﺮ أﻧﺎ اﻟﻤﻮﻗﻊ أدﻧﺎه ﺑﺄن ﺟﻤﻴﻊ اﻟﺒﻴﺎﻧﺎت واﻟﻤﻌﻠﻮﻣﺎت اﻟﻮاردة ﺑﻬﺬا اﻟﻄﻠﺐ ﺻﺤﻴﺤﺔ وأﻧﻨﻲ‬
that I/We have not misstated or suppressed any material facts. .‫ﻟﻢ أﻗﻢ ﺑﺈﻋﻄﺎء أي ﻣﻌﻠﻮﻣﺎت ﺧﺎﻃﺌﺔ أو ﺑﺘﺤﺮﻳﻒ أو إﺧﻔﺎء أي ﻣﻌﻠﻮﻣﺎت ﺟﻮﻫﺮﻳﺔ‬

I/We agree that this proposal, together with any other information supplied by ‫ﺟﺎﻧﺒﻨﺎ‬/‫ﻧﻮاﻓﻖ ﻋﻠﻰ أن ﻫﺬا اﻟﻄﻠﺐ وأي ﻣﻌﻠﻮﻣﺎت أﺧﺮى ﺗﻢ ﺗﻘﺪﻳﻤﻬﺎ ﻣﻦ ﺟﺎﻧﺒﻲ‬/‫أواﻓﻖ‬
me/us, shall form the basis of any contract of insurance effected thereon. .‫ﺗﻌﺘﺒﺮ أﺳﺎس أي ﻋﻘﺪ ﺗﺄﻣﻴﻦ ﻳﺘﻢ ﺗﻔﻌﻴﻠﻪ ﻣﻊ ﺷﺮﻛﺔ ﺳﻮﻟﻴﺪرﺗﻲ‬

Will notify the Saudi Credit Bureau (SIMAH) in the event of non-compliance with ‫ﺳﻮف ﻳﺘﻢ إﺷﻌﺎر اﻟﺸﺮﻛﺔ اﻟﺴﻌﻮدﻳﺔ ﻟﻠﻤﻌﻠﻮﻣﺎت اﻻﺋﺘﻤﺎﻧﻴﺔ )ﺳﻤﺔ( ﻓﻲ ﺣﺎل ﻋﺪم اﻟﺘﻘﻴﺪ‬
financial obligations. .‫ﺑﺎﻻﻟﺘﺰاﻣﺎت اﻟﻤﺎﻟﻴﺔ‬

Signing this proposal form does not bind the proposer or company to complete ‫ﺗﻮﻗﻴﻊ ﻫﺬا اﻟﻄﻠﺐ ﻻ ﻳﻠﺰم ﻃﺎﻟﺐ اﻟﺘﺄﻣﻴﻦ أو ﺷﺮﻛﺔ اﻟﺘﺄﻣﻴﻦ إﺗﻤﺎم ﻫﺬا اﻟﺘﺄﻣﻴﻦ‬
this insurance.

Date: :‫اﻟﺘﺎرﻳﺦ‬

For and behalf of: (Insert name of firm) (‫اﻟﻤﻨﺸﺄة‬

ُ ‫)أذﻛﺮ إﺳﻢ‬ :‫وﻗﻌﻬﺎ ﻧﻴﺎﺑﺔ ﻋﻦ‬

Signature of partner or principal: :‫ﺗﻮﻗﻴﻊ اﻟﺸﺮﻳﻚ أو اﻟﻤﺎﻟﻚ‬

SCOPE OF COVER ‫ﻧﻄﺎق اﻟﺘﻐﻄﻴﺔ اﻟﺘﺄﻣﻴﻨﻴﺔ‬

Protects medical professionals against legal liability for breach of professional ‫ﺗﺄﻣﻴﻦ أﺧﻄﺎء ﻣﻤﺎرﺳﺔ اﻟﻤﻬﻦ اﻟﻄﺒﻴﺔ ﻳﺤﻤﻲ اﻟﻤﻤﺎرس اﻟﻄﺒﻲ ﺿﺪ اﻟﻤﺴﺆوﻟﻴﺔ اﻟﻘﺎﻧﻮﻧﻴﺔ‬
duty in the conduct of their professional practice. .‫ﺧﻼل ﺑﺎﻟﻮاﺟﺐ اﻟﻤﻬﻨﻲ ﻓﻲ ﺗﻘﺪﻳﻢ اﻟﺨﺪﻣﺔ اﻟﻄﺒﻴﺔ اﻟﻤﻬﻨﻴﺔ‬º‫ﺑﺴﺒﺐ ا‬

Policy Provides cover for: :‫اﻟﻮﺛﻴﻘﺔ ﺗﻐﻄﻲ‬

1. Compensatory damages against the medical professionals .‫اﻟﻤﺨﺘﺼﺔ ﺿﺪ اﻟﻤﻤﺎرس اﻟﻄﺒﻲ‬ ُ ‫ اﻟﺘﻌﻮﻳﻀﺎت اﻟﻤﺤﻜﻮم ﺑﻬﺎ ﻣﻦ ﻗﺒﻞ اﻟﻠﺠﺎن أو اﻟﻤﺤﺎﻛﻢ‬.١
2. Legal costs and expenses associated with defending legal actions ‫أو ﺑﺎﻟﺘﺴﻮﻳﺔ ﻓﻲ أي‬/‫واﻟﻤﺘﻌﻠﻘﺔ ﺑﺎﻟﺪﻓﺎع و‬
ُ ‫اﻟﻤﺘﻜﺒﺪة‬
ُ ‫ اﻟﻤﺼﺎرﻳﻒ واﻟﺘﻜﺎﻟﻴﻒ اﻟﻘﺎﻧﻮﻧﻴﺔ‬.٢
.‫ﻣﻄﺎﻟﺒﺔ‬

Solidarity Saudi Takaful Company ‫ﺷﺮﻛﺔ ﺳﻮﻟﻴﺪرﺗﻲ اﻟﺴﻌﻮدﻳﺔ ﻟﻠﺘﻜﺎﻓﻞ‬

Head Office - Phone +966 11 299 4555 Fax +966 11 299 4556 +966 11 2994556 ‫ ﻓﺎﻛﺲ‬+966 11 2994555 ‫ﻫﺎﺗﻒ‬
PO Box 85770 - Riyadh 11612 Kingdom of Saudi Arabia ‫ اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﻴﺔ اﻟﺴﻌﻮدﻳﺔ‬11612 ‫ اﻟﺮﻳﺎض‬- 85770 .‫ب‬.‫ص‬
info@solidarity.sa www.solidarity.sa info@solidarity.sa