‫ﺑﻬﺬﺍ ﻧﺸﻬﺪ ﺑﺄﻥ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﻮﺻﻮﻑ ﺑﻴﺎﻧﺎﺗﻬﺎ ﺃﺩﻧﺎﻩ ﻣﺆﻣﻨﺔ ﻟﺪﻳﻨﺎ ﺗﺄﻣﻴﻨﺎ ﺷﺎﻣﻼ ﺑﻤﻮﺟﺐ ﺍﺣﻜﺎﻡ‬

‫ﻭﺷﺮﻭﻁ ﺍﻟﻮﺛﻴﻘﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ﺍﻟﺼﺎﺩﺭﺓ ﻣﻦ ﺷﺮﻛﺔ ﺍﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ‬

This is to certify that the below referred vehicle is comprehensively insured in
accordance with terms and condition of the main policy issued by AXA
insurance company

CERTIFICATE OF MOTOR VEHICLE : ‫ﺷﻬﺎﺩﺓ ﺗﺄﻣﻴﻦ ﺍﻟﺴﻴﺎﺭﺓ ﺭﻗﻢ‬

INSURANCE NO : 2/VA/10830270/0/1 2/VA/10830270/0/1
INSURED NAME :MOHAMMAD PARVEZ NAGRA AHMEDDIN ‫ ﻣﺤﻤﺪ ﺑﺮﻓﻴﺰ ﻧﺎﺟﺮﺍ ﺃﺣﻤﺪ ﺩﻳﻦ‬:‫ﺇﺳﻢ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
MOTOR VEHICLE DETAILS : : ‫ﺗﻔﺎﺻﻴﻞ ﺍﻟﺴﻴﺎﺭﺓ‬
Registration No : KKJ 5038 ٥٠٣٨ ‫ ﺡ ﻙ ﻙ‬: ‫ﺭﻗﻢ ﺍﻟﻠﻮﺣﺔ‬
Chassis No : JTJJM7FX4F5112234 JTJJM7FX4F5112234 : ‫ﺭﻗﻢ ﺍﻟﻬﻴﻜﻞ‬
Make : Lexus GX 460 GX 460 ‫ ﻟﻜﺰﺱ‬: ‫ﻧﻮﻉ ﺍﻟﺴﻴﺎﺭﺓ‬
Year : 2015 ٢٠١٥ : ‫ﺍﻟﻤﻮﺩﻳﻞ‬
Custom Card ID : : ‫ﺭﻗﻢ ﺍﻟﺒﻄﺎﻗﺔ ﺍﻟﺠﻤﺮﻛﻴﺔ‬
PERIOD OF INSURANCE : : ‫ﻣﺪﺓ ﺍﻟﺘﺄﻣﻴﻦ‬
Commencement date : 21/01/1442 (H) ‫ﻫﺠﺮﻳﺔ‬ ١٤٤٢/٠١/٢١ : ‫ﺗﺎﺭﻳﺦ ﺍﻹﺑﺘﺪﺍﺀ‬
Expiry date : 30/01/1443 (H) ‫ﻫﺠﺮﻳﺔ‬ ١٤٤٣/٠١/٣٠ : ‫ﻭﻳﻨﺘﻬﻲ ﻓﻲ‬
Corresponding to : From 08/09/2020 To 07/09/2021 30/01/1443 (H) 21/01/1442 (H)
Subject always to the Limits of Liability of 10,000,000 S.R. as ‫ ﺭﺱ ﺍﻟﻤﺒﻴﻨﺔ ﻓﻲ ﺍﻟﻮﺛﻴﻘﺔ ﻭﺍﻟﻨﺎﺗﺠﺔ‬١٠،٠٠٠،٠٠٠ ‫ﻭﺫﻟﻚ ﺿﻤﻦ ﺣﺪﻭﺩ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ‬
provided in the Policy arising out of the use of the insured Motor ‫ﻹﺳﺘﺨﺪﺍﻡ ﺍﻟﺴﻴﺎﺭﺓ‬
Vehicle within Saudi Arabia .
‫ﺍﻟﻤﺆﻣﻨﺔ ﺩﺍﺧﻞ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬
This Certificate is deemed to be a guarantee for payment for all
amounts which the Insured Owner and/or the Authorized Driver at
‫ﻭﺗﻌﺘﺒﺮ ﻫﺬﻩ ﺍﻟﺸﻬﺎﺩﺓ ﻛﻀﻤﺎﻥ ﻟﺪﻓﻊ ﻛﺎﻓﺔ ﺍﻟﻤﺒﺎﻟﻎ ﺍﻟﺘﻲ ﻳﻜﻮﻥ ﺍﻟﻤﺎﻟﻚ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﺃﻭ‬
the time of the accident shall become legally liable to pay as ‫ ﺍﻟﻮﻓﺎﺓ ﺃﻭ ﺍﻹﺻﺎﺑﺔ ﺍﻟﺒﺪﻧﻴﺔ ﺍﻟﺘﻲ ﺗﺤﺪﺙ ﻷﻱ ﺷﺨﺺ ﺑﻤﺎ ﻓﻲ ﺫﻟﻚ‬. 1
compensation for ‫ﺭﻛﺎﺏ ﺍﻟﺴﻴﺎﺭﺓ‬
(a) Death or bodily injury sustained by any person including ‫ ﺗﻠﻒ ﻣﻤﺘﻠﻜﺎﺕ ﺃﻱ ﻃﺮﻑ ﺛﺎﻟﺚ ﺧﺎﺭﺝ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﺆﻣﻨﺔ‬. 2
passengers of the vehicle
(b) Damage to third party property outside the Insured Vehicle
SIGNED : : ‫ﺍﻟﺘﻮﻗﻴﻊ‬

Gary M.Lewin ‫ ﻟﻴﻮﻳﻦ‬.‫ﺟﺎﺭﻱ ﻡ‬

Chief Executive Officer ‫ﺍﻟﺮﺋﻴﺲ ﺍﻟﺘﻨﻔﻴﺬﻱ‬

IMPORTANT
‫ﻣﻼﺣﻄﺎﺕ ﻫﺎﻣﺔ‬
1. This certificate of Insurance and Policy is valid only for the ‫ ﺇﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺘﺄﻣﻴﻦ ﻫﺬﻩ ﺻﺎﻟﺤﺔ ﻓﻘﻂ ﻟﻠﻤﺎﻟﻚ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻭﺍﻟﺴﺎﺋﻖ ﺍﻟﻤﺨﻮﻝ ﻟﻪ‬. 1
Insured Owner and the authorized Driver at the time of ‫ﺑﺎﻟﻘﻴﺎﺩﺓ ﻓﻲ ﺣﺎﻟﺔ ﻭﻗﻮﻉ ﺣﺎﺩﺙ ﻭﻫﻲ ﻏﻴﺮ ﻗﺎﺑﻠﺔ ﻟﻠﺘﺤﻮﻳﻞ ﺑﺪﻭﻥ ﻣﻮﺍﻓﻘﺔ‬
Accident and is NOT transferable without prior consent ‫ﻣﺴﺒﻘﺔ ﻣﻦ ﻗﺒﻞ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
of the Insurance Company.
2. Any Accident must be notified to the Insurance . ‫ ﻋﻨﺪ ﻭﻗﻮﻉ ﺃﻱ ﺣﺎﺩﺙ ﻳﺠﺐ ﺇﺧﻄﺎﺭ ﺍﻟﺸﺮﻛﺔ ﻓﻮﺭﺍ‬. 2
Company immediately.

AXA Cooperative Insurance Company CR-No 1010271203 P.O.Box 812 ٢١٤٢١ ‫ ﺟﺪﺓ‬٨١٢ ‫ ﺹ ﺏ‬١٠١٠٢٧١٢٠٣: ‫ﺷﺮﻛﺔ ﺃﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﺱ ﺕ‬,
Jeddah 21421, Madina Road, Kilo 7, Kanoo Building No. 2, 3rd floor, ‫ ﺍﻟﻄﺎﺑﻖ ﺍﻟﺜﺎﻟﺚ‬,٢ ‫ ﻣﺒﻨﻰ ﻛﺎﻧﻮ ﺭﻗﻢ‬,٧ ‫ ﺍﻟﻜﻴﻠﻮ‬,‫ﻃﺮﻳﻖ ﺍﻟﻤﺪﻳﻨﺔ‬
Jeddah, KSA. ٠٠٩٦٦ (١٢) ٢٦٣٢٩٠٤ : ‫ﻓﺎﻛﺲ‬
Telephone : 8001160020 ٨٠٠١١٦٠٠٢٠ :‫ﻫﺎﺗﻒ‬
Fax : 00966 (12) 2632904 www.axa-cooperative.com : ‫ﺍﻟﻤﻮﻗﻊ ﺍﻹﻟﻜﺘﺮﻭﻧﻲ‬
Email :motorclaims.reg-ksa@axa-cooperative.com motorclaims.reg-ksa@axa-cooperative.com:‫ﺍﻟﺒﺮﻳﺪ ﺍﻻﻟﻜﺘﺮﻭﻧﻲ‬
Website :www.axa-cooperative.com ‫ ﻭﺗﺤﻤﻞ ﺭﺧﺼﺔ ﺗﺄﻣﻴﻦ ﺭﻗﻢ‬١٠١٠٢٧١٢٠٣ ‫ﺷﺮﻛﺔ ﻣﺴﺠﻠﺔ ﻓﻲ ﻭﺯﺍﺭﺓ ﺍﻟﺼﻨﺎﻋﺔ ﻭﺍﻟﺘﺠﺎﺭﺓ ﻟﻠﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﺑﺴﺠﻞ ﺗﺠﺎﺭﻱ ﺭﻗﻢ‬
TMN/25/20101 ‫ ﺻﺎﺩﺭﺓ ﻣﻦ ﻗﺒﻞ ﻣﺆﺳﺴﺔ ﺍﻟﻨﻘﺪ ﺍﻟﻌﺮﺑﻲ ﺍﻟﺴﻌﻮﺩﻱ‬.