‫ﻃﻮﻛﻴﻮ ﻣﺎﺭﻳﻦ ﺍﻧﺪ ﻧﻴﺘﺸﻴﺪﻭ ﻓﺎﻳﺮ‬ TOKIO MARINE & NICHIDO FIRE

‫ﺍﻧﺸﻮﺭﺍﻧﺲ ﻛﻮﻣﺒﺎﻧﻲ ﻟﻴﻤﻴﺘﺪ‬ INSURANCE CO., LTD.

‫ﻣﻜﺘﺐ ﺩﺑﻲ‬: Dubai Office:
‫ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ‬،‫ ﺩﺑﻲ‬،١٥٢ ‫ ﺑﺮﻳﺪ‬:‫ﺹ ﺏ‬ P.O. BOX 152, Dubai, UAE
+٩٧١ ٤ ٣٥٠٢ ٨٨٨ : ‫ ﻓﺎﻛﺲ‬، + ٩٧١ ٤ ٣٥٠٢ ٧٧٧ :‫ﻫﺎﺗﻒ‬ Tel: +971-4-3502 777,Fax: +971-4-3502 888
‫ﻣﻜﺘﺐ ﺃﺑﻮﻇﺒﻲ‬ Abu Dhabi Office:
‫ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ‬،‫ ﺃﺑﻮﻇﺒﻲ‬،٥١٥٣١ ‫ ﺑﺮﻳﺪ‬:‫ﺹ ﺏ‬ P.O. Box 51531,Abu Dhabi, UAE
+٩٧١ ٢ ٦٤٣٢ ٢٩٤ : ‫ ﻓﺎﻛﺲ‬، + ٩٧١ ٢ ٦٤٣٢ ٢٩٠ :‫ﻫﺎﺗﻒ‬ Tel: +971-2-6432 290,Fax: +971-2-6432 294
http://www.tmnf.ae http://www.tmnf.ae
(Incorporated in japan, registered in the Insurance Companies register under Regn. No. 45 dated 29th December 1984)
AGENTS FOR UNITED ARAB EMIRATES: AL FUTTAIM DEVELOPMENT SERVICES CO. LLC.

MOTOR SCHEDULE ‫ﺍﻟﺠﺪﻭﻝ‬

COMPREHENSIVE TOKIO MUST ‫ﺍﻟﺘﺎﻣﻴﻦ ﺿﺪ ﺍﻟﻔﻘﺪ ﻭ ﺍﻟﺘﻠﻒ ﻭﺍﻟﻤﺴﺆﻟﻴﺔ ﺍﻟﻤﺪﻧﻴﺔ‬
Name of Insured: JAFAR AROTH : ‫ ﺍﺳﻢ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬Policy Number : P-100-1006-2023-23412 : ‫ﺭﻗﻢ ﺍﻟﻮﺛﻴﻘﺔ‬
POYIL ABDUL
NAZAR
UMMARAKKUZHI
PURAYIL
Address : DUBAI : ‫ ﺍﻟﻌﻨﻮﺍﻥ‬Date of issue : 29/03/2023 : ‫ﺗﺎﺭﻳﺦ‬
DUBAI ‫ﺍﻻﺻﺪﺍﺭ‬
Client No. : 00900000054 : ‫ ﺭﻣﺰ ﺍﻟﻌﻤﻴﻞ‬Mobile : 0528316823 : ‫ﻣﻮﺑﺎﻳﻞ‬
Assured No. : 0010596171 : ‫ ﺭﻣﺰ ﺍﻟﻤﺆﻣﻦ‬Phone : : ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
Mortgaged To : : ‫ ﻣﺮﻫﻮﻧﺔ‬Email : zeeshan@geinsurance.ae : ‫ﺍﻟﺒﺮﻳﺪ‬
‫ﻟﺼﺎﻟﺢ‬ ‫ﺍﻹﻟﻜﺘﺮﻭﻧﻲ‬
Period of Insurance: From 29/03/2023 22:27 To 28/04/2024 23:59 : ‫ﻣﺪﺓ ﺍﻟﺘﺄﻣﻴﻦ‬
Premium Details : : ‫ﺗﻔﺎﺻﻴﻞ ﻗﻴﻤﺔ ﺍﻟﻘﺴﻂ‬
Own Damage : AED 680.37 : ‫ﺿﺪ ﺍﻟﻔﻘﺪ ﻭ ﺍﻟﺘﻠﻒ‬
Third Party Liability: AED 439.63 : ‫ﺿﺪ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ ﺍﻟﻤﺪﻧﻴﺔ‬
Value Added TAX : AED 56.00 : ‫ﺿﺮﻳﺒﺔ ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ‬
Total : AED 1,176.00 : ‫ﻣﺠﻤﻮﻉ‬

Deductibles : : ‫ﺍﻟﺘﺤﻤﻞ ﺍﻻﺟﺒﺎﺭﻱ‬

STD MIN DED AED 250.00

Insured vehicle : ‫ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
‫ﻧﻮﻉ ﺍﻟﻤﺮﻛﺒﺔ‬ ‫ﻧﻤﻮﺫﺝ ﺍﻟﻤﺮﻛﺒﺔ‬ ‫ﺳﻨﺔ ﺍﻟﺼﻨﻊ‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ ﺍﻷﻭﻝ‬ ‫ﺭﻗﻢ ﺍﻟﻠﻮﺣﺔ‬ ‫ﺭﻗﻢ ﺍﻟﻘﺎﻋﺪﺓ‬ ‫ﺭﻗﻢ ﺍﻟﻤﺤﺮﻙ‬
Vehicle Make Vehicle Model Model Year Date of First Registration Chassis Engine Number
Registration Number Number
‫ﺗﻮﻳﻮﺗﺎ‬
TOYOTA COROLLA SPORT 2015 01/01/2015 RKLBB9HE4F50 Y049519
38501
‫ﻋﺪﺩ ﺍﻻﺳﻄﻮﺍﻧﺎﺕ‬ ‫ﺳﻌﺔ ﺍﺳﻄﻮﺍﻧﺎﺕ ﺍﻟﻤﺤﺮﻙ‬ ‫ﻋﺪﺩ ﺍﻟﺮﻛﺎﺏ ﻣﻊ‬ ‫ﺍﻟﻠﻮﻥ‬ ‫ﺻﻔﺔ ﺍﻻﺳﺘﻌﻤﺎﻝ‬ ‫ﺷﻜﻞ ﺍﻟﻤﺮﻛﺒﺔ‬ ‫ﺍﻟﺤﺪﻭﺩ ﺍﻟﺠﻐﺮﺍﻓﻴﺔ‬
‫ﺍﻟﺴﺎﺋﻖ‬
No of CC Seating Colour Use of Vehicle Vehicle Geographical
Cylinders Capacity Segment Area
‫ﺍﺑﻴﺾ‬ ‫ﺧﺼﻮﺻﻲ‬ ‫ﺍﻹﻣﺎﺭﺍﺕ‬
‫ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ‬
‫ﻭ*ﺳﻠﻄﻨﺔ ﻋﻤﺎﻥ‬
(*‫ﺿﺪ ﺍﻟﻔﻘﺪ ﻭﺍﻟﺘﻠﻒ‬
‫)ﻗﻔﻂ‬
FOUR NA 4+1 WHITE PRIVATE B1-SALOON U.A.E and
*SULTANATE OF
OMAN (*Own
Damage Cover
only)
 ‫ﻃﻮﻛﻴﻮ ﻣﺎﺭﻳﻦ ﺍﻧﺪ ﻧﻴﺘﺸﻴﺪﻭ ﻓﺎﻳﺮ‬ TOKIO MARINE & NICHIDO FIRE
‫ﺍﻧﺸﻮﺭﺍﻧﺲ ﻛﻮﻣﺒﺎﻧﻲ ﻟﻴﻤﻴﺘﺪ‬ INSURANCE CO., LTD.
‫ﻣﻜﺘﺐ ﺩﺑﻲ‬: Dubai Office:
‫ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ‬،‫ ﺩﺑﻲ‬،١٥٢ ‫ ﺑﺮﻳﺪ‬:‫ﺹ ﺏ‬ P.O. BOX 152, Dubai, UAE
+٩٧١ ٤ ٣٥٠٢ ٨٨٨ : ‫ ﻓﺎﻛﺲ‬، + ٩٧١ ٤ ٣٥٠٢ ٧٧٧ :‫ﻫﺎﺗﻒ‬ Tel: +971-4-3502 777,Fax: +971-4-3502 888
‫ﻣﻜﺘﺐ ﺃﺑﻮﻇﺒﻲ‬ Abu Dhabi Office:
‫ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ‬،‫ ﺃﺑﻮﻇﺒﻲ‬،٥١٥٣١ ‫ ﺑﺮﻳﺪ‬:‫ﺹ ﺏ‬ P.O. Box 51531,Abu Dhabi, UAE
+٩٧١ ٢ ٦٤٣٢ ٢٩٤ : ‫ ﻓﺎﻛﺲ‬، + ٩٧١ ٢ ٦٤٣٢ ٢٩٠ :‫ﻫﺎﺗﻒ‬ Tel: +971-2-6432 290,Fax: +971-2-6432 294
http://www.tmnf.ae http://www.tmnf.ae
(Incorporated in japan, registered in the Insurance Companies register under Regn. No. 45 dated 29th December 1984)
AGENTS FOR UNITED ARAB EMIRATES: AL FUTTAIM DEVELOPMENT SERVICES CO. LLC.

Sum Insured : AED 49,200.00 49,200.00 AED : ‫ﻣﺒﻠﻎ ﺍﻟﺘﺄﻣﻴﻦ‬

Type of Policy
COMPREHENSIVE TOKIO MUST - Own Damage
Limit of Liability/Memoranda/Conditions/Endorsements
Endorsements no.1,2,3 in the clause attached shall apply only if stated herein the schedule

24hrs Roadside Side Assistance: AAA cover : 600 50 8181

Personal Accident Benefit to the Driver: Applicable (As per Endorsement No. 1)
Limit: AED 200,000.00 any one occurrence
Personal Accident Benefit to the Passengers: Applicable (As per Endorsement No. 1)
Limit: AED 200,000.00 per passenger any one occurrence.
Number of passengers covered: As per seating capacity of the vehicle.
Hire Charge for Rent A Car: Applicable (As per Endorsement No. 3.) However, the maximum Rent A Car hire period
applicable will be 20 days.
Limit Per day: AED 100/-
Maximum Number of days allowed: 20 days
Oman Cover - Own Damage Only
Self Authorization Limit:The maximum Authorised Repair Limit '
with regard to the Insured's right to repair as per Clause 4 under
Chapter 2 of Section One is AED 1,000/-

Agency Repairs Eligibility: NIL

The Insured must not use the vehicle except for the purpose for it is mentioned
For any accident involving a driver underage 25,additional 10% deductible will be applied as per policy conditions

COMPREHENSIVE TOKIO MUST - Third Party Section

Limit of Liability/Memoranda/Conditions/Endorsements
1. The Company's maximum liability in respect of paragraph (a) of Clause 1 under Chapter 2 of Section two in
respect of any one claim or series of claims resulting from one accident is the sum awarded by the UAE Court.

2. The Company's maximum liability respect of paragraph (c) of Clause 1 under Chapter 2 of Section two in respect
of any one claim or series of claims resulting from one accident is AED 3,000,000.

National Ambulance Service Cover

‫ﻧﻮﻉ ﺍﻟﺘﺄﻣﻴﻦ‬
‫ ﺍﻟﺘﺎﻣﻴﻦ ﺿﺪ ﺍﻟﻔﻘﺪ ﻭ ﺍﻟﺘﻠﻒ ﻭﺍﻟﻤﺴﺆﻟﻴﺔ ﺍﻟﻤﺪﻧﻴﺔ‬- ‫ﺍﻟﺠﺰﺀ ﺿﺪ ﺍﻟﻔﻘﺪ ﻭ ﺍﻟﺘﻠﻒ‬
‫ﺗﺤﺪﻳﺪ ﻣﻦ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ \ ﻣﺬﻛﺮﺍﺕ \ ﺷﺮﻭﻁ \ ﻣﻼﺣﻖ‬
‫ ﺍﻟﻮﺍﺭﺩﺓ ﻓﻲ ﺍﻟﺒﻨﺪ ﺍﻟﻤﺮﻓﻖ ﺇﻻ ﺇﺫﺍ ﺗﻢ ﺫﻛﺮﻫﺎ ﻓﻲ ﺍﻟﺠﺪﻭﻝ‬٣ ،٢ ،١ ‫ﻻ ﺗﻨﻄﺒﻖ ﺍﻟﻤﻮﺍﺛﻴﻖ ﺭﻗﻢ‬

٨٠٠٤٩٠٠ :‫ ﺗﻐﻄﻴﺔ ﺗﺄﻣﻴﻨﻴﺔ ﺃ ﺃ ﺃ ﻫﺎﺗﻒ ﻣﺠﺎﻧﻲ‬:‫ ﺳﺎﻋﺔ‬٢٤ ‫ﺧﺪﻣﺔ ﺍﻹﻧﻘﺎﺫ ﺍﻟﺴﺮﻳﻊ ﻋﻠﻰ ﺍﻟﻄﺮﻳﻖ‬
"‫ ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍﺗﻲ ﻋﻦ ﺃﻱ ﺣﺎﺩﺛﺔ ﺗﻘﻊ‬٢٠٠،٠٠٠ :‫( ﺍﻟﺤﺪ‬١ ‫ ﺳﺎﺭﻱ )ﺑﺤﺴﺐ ﻣﺎ ﻭﺭﺩ ﺑﺎﻟﺘﺠﻴﻴﺮ ﺭﻗﻢ‬:‫ﺍﺳﺘﻔﺎﺩﺓ ﺍﻟﺴﺎﺋﻖ ﻣﻦ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺸﺨﺼﻲ‬
‫ ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍﺗﻲ ﺑﻲ ﺍﻱ ﺍﻡ ﺗﻲ ﻟﻜﻞ ﻣﺴﺎﻓﺮ ﻋﻦ ﻛﻞ ﺣﺎﺩﺛﺔ‬:‫( ﺍﻟﺤﺪ‬١ ‫ ﻣﻌﻤﻮﻝ ﺑﻪ )ﺑﺤﺴﺐ ﻣﺎ ﻭﺭﺩ ﻓﻲ ﺍﻟﺘﺠﻴﻴﺮ ﺭﻗﻢ‬:‫ﺍﺳﺘﻔﺎﺩﺓ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﻣﻦ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺸﺨﺼﻲ‬
‫ ﺑﺤﺴﺐ ﺍﻟﻘﺪﺭﺓ ﺍﻻﺳﺘﻴﻌﺎﺑﻴﺔ ﻟﻤﻘﺎﻋﺪ ﺍﻟﻤﺮﻛﺒﺔ‬:‫ﻋﺪﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻤﺸﻤﻮﻟﻴﻦ ﺑﺎﻟﺘﺄﻣﻴﻦ‬
 ‫ﻃﻮﻛﻴﻮ ﻣﺎﺭﻳﻦ ﺍﻧﺪ ﻧﻴﺘﺸﻴﺪﻭ ﻓﺎﻳﺮ‬ ‫‪TOKIO MARINE & NICHIDO FIRE‬‬
‫ﺍﻧﺸﻮﺭﺍﻧﺲ ﻛﻮﻣﺒﺎﻧﻲ ﻟﻴﻤﻴﺘﺪ‬ ‫‪INSURANCE CO., LTD.‬‬
‫‪:‬ﻣﻜﺘﺐ ﺩﺑﻲ‬ ‫‪Dubai Office:‬‬
‫ﺹ ﺏ‪ :‬ﺑﺮﻳﺪ ‪ ،١٥٢‬ﺩﺑﻲ‪ ،‬ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ‬ ‫‪P.O. BOX 152, Dubai, UAE‬‬
‫ﻫﺎﺗﻒ‪ ، + ٩٧١ ٤ ٣٥٠٢ ٧٧٧ :‬ﻓﺎﻛﺲ ‪+٩٧١ ٤ ٣٥٠٢ ٨٨٨ :‬‬ ‫‪Tel: +971-4-3502 777,Fax: +971-4-3502 888‬‬
‫ﻣﻜﺘﺐ ﺃﺑﻮﻇﺒﻲ‬ ‫‪Abu Dhabi Office:‬‬
‫ﺹ ﺏ‪ :‬ﺑﺮﻳﺪ ‪ ،٥١٥٣١‬ﺃﺑﻮﻇﺒﻲ‪ ،‬ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﻤﺘﺤﺪﺓ‬ ‫‪P.O. Box 51531,Abu Dhabi, UAE‬‬
‫ﻫﺎﺗﻒ‪ ، + ٩٧١ ٢ ٦٤٣٢ ٢٩٠ :‬ﻓﺎﻛﺲ ‪+٩٧١ ٢ ٦٤٣٢ ٢٩٤ :‬‬ ‫‪Tel: +971-2-6432 290,Fax: +971-2-6432 294‬‬
‫‪http://www.tmnf.ae‬‬ ‫‪http://www.tmnf.ae‬‬
‫)‪(Incorporated in japan, registered in the Insurance Companies register under Regn. No. 45 dated 29th December 1984‬‬
‫‪AGENTS FOR UNITED ARAB EMIRATES: AL FUTTAIM DEVELOPMENT SERVICES CO. LLC.‬‬

‫ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﺍﻟﻌﻤﺎﻧﻴﺔ ‪ -‬ﺍﻟﻀﺮﺭ ﺍﻟﺸﺨﺼﻲ ﻓﻘﻂ‬

‫ﺣﺪ ﺍﻟﺘﻔﻮﻳﺾ ﺍﻟﺬﺍﺗﻲ‪ :‬ﺍﻟﺤﺪ ﺍﻷﻗﺼﻰ ﺍﻟﻤﺴﻤﻮﺡ ﺑﻪ ﻟﻺﺻﻼﺣﺎﺕ ﺍﻟﻤﺘﻌﻠﻘﺔ ﺑﺤﻖ ﺍﻟﻤﺆﻣﻦ ﻋﻠﻴﻪ ﻓﻲ ﺇﺟﺮﺍﺀ ﺍﻹﺻﻼﺣﺎﺕ ﺑﺤﺴﺐ ﻣﺎ ﻭﺭﺩ ﻓﻲ ﺍﻟﺒﻨﺪ ‪ ٤‬ﻣﻦ ﺍﻟﻔﺼﻞ ﺍﻟﺜﺎﻧﻲ ﺍﻟﻘﺴﻢ ‪ ١‬ﻫﻮ ‪"١،٠٠٠‬‬
‫ﺩﺭﻫﻢ ﺇﻣﺎﺭﺍﺗﻲ‪ -/‬ﺍﻟﺘﻐﻄﻴﺔ ﺍﻟﺘﺄﻣﻴﻨﻴﺔ ﻋﻦ ﺍﻟﺘﻠﻔﻴﺎﺕ ﺍﻟﻨﺎﺗﺠﺔ ﻋﻦ ﺍﻟﻌﻮﺍﺻﻒ ﻭﺍﻟﻔﻴﻀﺎﻧﺎﺕ ﻭﺍﻹﺿﺮﺍﺑﺎﺕ ﻭﺃﻋﻤﺎﻝ ﺍﻟﺸﻐﺐ ﻭﺍﻝ‬
‫ﻳﺠﺐ ﺃﻻ ﻳﺴﺘﺨﺪﻡ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﺍﻟﻤﺮﻛﺒﺔ ﺇﻻ ﻟﻠﻐﺮﺽ ﺍﻟﻤﺬﻛﻮﺭ‬
‫ﻭﻓﻲ ﺣﺎﻟﺔ ﻭﻗﻮﻉ ﺃﻱ ﺣﺎﺩﺙ ﻳﻨﻄﻮﻱ ﻋﻠﻰ ﺳﺎﺋﻖ ﻳﻘﻞ ﻋﻤﺮﻩ ﻋﻦ ‪ ٢٥‬ﻋﺎﻣﺍ‪ ،‬ﺳﻮﻑ ﻳﺴﺮﻯ ﻣﺒﻠﻎ ﻣﻘﺘﻄﻊ ﺇﺿﺎﻓﻲ ﺑﻨﺴﺒﺔ ‪ %١٠‬ﻭﻓﻘﺍ ﻟﺸﺮﻭﻁ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫ﺍﻟﺠﺰﺀ ﺿﺪ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ ﺍﻟﻤﺪﻧﻴﺔ ‪ -‬ﺍﻟﺘﺎﻣﻴﻦ ﺿﺪ ﺍﻟﻔﻘﺪ ﻭ ﺍﻟﺘﻠﻒ ﻭﺍﻟﻤﺴﺆﻟﻴﺔ ﺍﻟﻤﺪﻧﻴﺔ‬
‫ﺗﺤﺪﻳﺪ ﻣﻦ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ \ ﻣﺬﻛﺮﺍﺕ \ ﺷﺮﻭﻁ \ ﻣﻼﺣﻖ‬
‫ﺍﻟﺤﺪ ﺍﻷﻗﺼﻰ ﻟﻤﺴﺆﻭﻟﻴﺔ ﺍﻟﺸﺮﻛﺔ ﻓﻴﻤﺎ ﻳﺘﻌﻠﻖ ﺑﺄﺣﻜﺎﻡ ﺍﻟﻘﺴﻢ )ﺃ( ﻣﻦ ﺍﻟﺒﻨﺪ ﺍﻷﻭﻝ ﺍﻟﻤﻨﺪﺭﺝ ﺗﺤﺖ ﺍﻟﻔﺼﻞ ﺍﻟﺜﺎﻧﻲ ﻣﻦ ﺍﻟﻘﺴﻢ ﺍﻟﺜﺎﻧﻲ ﺍﻟﻤﺘﺼﻞ ﺑﺄﻱ ﻣﻄﺎﻟﺒﺔ ﺃﻭ ﻣﺠﻤﻮﻋﺔ ﻣﻦ ‪1.‬‬
‫‪.‬ﺍﻟﻤﻄﺎﻟﺒﺎﺕ ﺗﻨﺸﺊ ﻋﻦ ﺣﺎﺩﺙ ﻭﺍﺣﺪ ﻳﻤﺜﻞ ﺍﻟﻤﺒﻠﻎ ﺍﻟﺬﻱ ﺗﻘﻀﻲ ﺑﻪ ﺍﻟﻤﺤﻜﻤﺔ ﺍﻹﻣﺎﺭﺍﺗﻴﺔ‬

‫ﺍﻟﺤﺪ ﺍﻷﻗﺼﻰ ﻟﻤﺴﺆﻭﻟﻴﺔ ﺍﻟﺸﺮﻛﺔ ﻓﻴﻤﺎ ‪2.‬‬

‫‪Name & Signature of the Insured or their representative‬‬

‫‪Authorized Signatory‬‬