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Receipt ‫ﺳﻨﺪ ﻗﺒﺾ‬

DUPLICATE
Branch : AXA Online Business
Receipt No. : 3611430
Issue Date : 21/05/2020 : ‫ﺃﻟﺘﺎﺭﻳﺦ‬
Client Number : 1073593 : ‫ﺃﻟﺮﻗﻢ‬
Client Name : Mohammad KHAN : ‫ﺃﻷﺳﻢ‬
Address : Unknown 1 AL JUBAIL SAUDI ARABIA : ‫ﺃﻟﻌﻨﻮﺍﻥ‬
Received From : : ‫ﻭﺻﻠﻨﺎ ﻣﻦ‬
Base Premium : 636.00 SAR : ‫ﺍﻟﻘﺴﻂ ﺍﻷﺟﻤﺎﻟﻲ‬
No Claim Discount : 2.00 SAR : ‫ﺍﻟﺨﺼﻢ‬
Claim Loading : 0.00 SAR : ‫ﺍﻟﻤﺒﻠﻎ ﺍﻟﻤﻀﺎﻑ ﻟﻮﺟﻮﺩ ﺣﻮﺍﺩﺙ‬
Remark : 1351303 : ‫ﻣﻼﺣﻈﺔ‬

Reference Number Mode Remark Amount


‫ﺭﻗﻢ ﺃﻟﻤﺮﺟﻊ‬ ‫ﺃﻟﺪﻓﻊ‬ ‫ﻣﻼﺣﻈﺔ‬ ‫ﺃﻟﻤﺒﻠﻎ‬

20/VP/16660/0/0 Motor Payment Ga VP1351303_SA_535151 666.00

TOTAL : 666.00

: ‫ﺃﻟﻤﺠﻤﻮﻉ‬
Six hundred sixty six and 00/100 Saudi Riyal ‫ ﻫﻠﻠﺔ ﻓﻘﻂ ﻻ ﻏﻴﺮ‬٠٠ ‫ﺳﺘﻤﺎﺋﺔ ﻭ ﺳﺘﺔ ﻭ ﺳﺘﻮﻥ ﺭﻳﺎﻝ ﺳﻌﻮﺩﻱ ﻭ‬
ONLY

Signed for and behalf of

AXA Online Business

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