‫ﺧﺎﺿﻌﺔ ﻟﺮﻗﺎﺑﺔ اﻟﺒﻨﻚ اﻟﻤﺮﻛﺰي اﻟﺴﻌﻮدي‬

‫‪www.malath.com.sa‬‬ ‫‪8001280088‬‬ ‫رﻗﻢ اﻟﺘﺮﺧﻴﺺ‪ :‬ت م ن ‪٢٠٠٧٩ / ٢ /‬‬

General Information ‫ﻣﻌﻠﻮﻣﺎت ﻋﺎﻣﺔ‬
Organization Name ‫اﺳﻢ اﻟﻤﻨﺸﺄة‬

Trading Name (if different than above) ( ‫ا‚ﺳﻢ اﻟﺘﺠﺎري )إذا ﻛﺎن ﻣﺨﺘﻠﻔ„ ﻋﻦ ا‚ﺳﻢ أﻋﻼه‬

Commercial Registration No. ‫رﻗﻢ اﻟﺴﺠﻞ اﻟﺘﺠﺎري‬

Unified Number Starting with (7) ( ٧) ‫اﻟﺮﻗﻢ اﻟﻤﻮﺣﺪ اﻟﻤﺒﺘﺪئ ﺑﺎﻟﺮﻗﻢ‬

Expiry Date of CR. ‫ﺗﺎرﻳﺦ اﻧﺘﻬﺎء اﻟﺴﺠﻞ اﻟﺘﺠﺎري‬

Organization Type ‫ﻧﻮع اﻟﻤﻨﺸﺄة‬

‫ﺷﺮﻛﺔ ذات ﻣﺴﺆوﻟﻴﺔ ﻣﺤﺪودة‬ ‫ﻣﺆﺳﺴﺔ ﻓﺮدﻳﺔ‬ ‫ﺷﺮﻛﺔ ﺗﻌﺎوﻧﻴﺔ‬ ‫ﺷﺮﻛﺔ ﺗﻀﺎﻣﻦ‬
L.L.C. Sole Proprietorship Cooperative Company Joint Liability Company

‫ﺟﻤﻌﻴﺔ ﺧﻴﺮﻳﺔ‬ (‫ﺟﻬﺔ ﺣﻜﻮﻣﻴﺔ )أو ﺷﺒﻪ ﺣﻜﻮﻣﻴﺔ‬ ‫ﺷﺮﻛﺔ ﻣﺴﺎﻫﻤﺔ ﻋﺎﻣﺔ‬ ‫ﺷﺮﻛﺔ ﺗﻮﺻﻴﺔ ﺑﺴﻴﻄﺔ‬
Charity Foundation Government (or Semi Government) PJSC Simple Commandite Company
‫أﺧﺮى‬
Others

Others (specify) ( ‫أﺧﺮى )اذﻛﺮﻫﺎ‬

Nature of Business of the Organization ‫ﻃﺒﻴﻌﺔ ﻋﻤﻞ اﻟﻤﻨﺸﺄة‬

City / Country Incorporation ‫ ﺑﻠﺪ ﺗﺄﺳﻴﺲ اﻟﻤﻨﺸﺄة‬/ ‫ﻣﺪﻳﻨﺔ‬

Date of Establishment ‫ﺗﺎرﻳﺦ اﻟﺘﺄﺳﻴﺲ‬

Legal Representative ID ‫رﻗﻢ اﻟﻤﻤﺜﻞ اﻟﻨﻈﺎﻣﻲ ﻟﻠﻤﻨﺸﺄة‬

VAT Number ‫اﻟﺮﻗﻢ اﻟﻀﺮﻳﺒﻲ‬

Legal Entity Identifier (if any) (‫رﻗﻢ ﻣﻌﺮف اﻟﻜﻴﺎن اﻟﻘﺎﻧﻮﻧﻲ )إن وﺟﺪ‬

Organization Phone Number ‫رﻗﻢ ﻫﺎﺗﻒ اﻟﻤﻨﺸﺄة‬

Organization Email ‫اﻟﺒﺮﻳﺪ ا‚ﻟﻜﺘﺮوﻧﻲ ﻟﻠﻤﻨﺸﺄة‬

Communication Channel with Malath ‫ﻗﻨﺎة اﻟﺘﻮاﺻﻞ ﻣﻊ ﻣﻼذ‬

‫ﻣﺒﺎﺷﺮ‬ ‫ﻣﺴﻮق‬ ‫وﺳﻴﻂ‬
Direct Producer Broker
Channel Name (Broker / Producer) ‫ اﻟﻮﺳﻴﻂ‬/ ‫اﺳﻢ اﻟﻤﺴﻮق‬

Sources of Fund ‫ﻣﺼﺎدر اﻟﺘﻤﻮﻳﻞ‬

‫أرﺑﺎح ﺗﺠﺎرﻳﺔ‬ ‫رأس اﻟﻤﺎل‬ ‫ﻣﻴﺮاث‬ ‫ ﻗﺮوض‬/ ‫ﺗﻤﻮﻳﻞ‬
Business Profit Capital Inheritance Financing / Loans
Others (specify) (‫أﺧﺮى )أذﻛﺮﻫﺎ‬

Your Company’s Total Annual Turnover ‫إﺟﻤﺎﻟﻲ ا
ﻳﺮادات اﻟﺴﻨﻮﻳﺔ ﻟﻠﻤﻨﺸﺄة‬

‫ ﻣﻠﻴﻮن وأﻛﺚ‬٢٠٠ ‫ ﻣﻠﻴﻮن‬٢٠٠-٤٠ ‫ ﻣﻠﻴﻮن‬٤٠-٣ ‫ ﻣﻠﻴﻮن‬٣-٠
200 Million & more 40-200 Million 3-40 Million 0-3 Million

Number of Employees in your Organization ‫ﻋﺪد اﻟﻌﺎﻣﻠﻴﻦ ﻓﻲ اﻟﻤﻨﺸﺄة‬

‫ وأﻛﺜﺮ‬٢٤٩ ٢٤٩-٥٠ ٤٩-٦ ٥-١
249 & more 50-249 6-49 1-5
Business Address ‫ﻋﻨﻮان اﻟﻌﻤﻞ‬
National Address (Wasel) (‫اﻟﻌﻨﻮان اﻟﻮﻃﻨﻲ )واﺻﻞ‬
P.O. Box ‫ب‬.‫ص‬

Postal Code ‫اﻟﺮﻣﺰ اﻟﺒﺮﻳﺪي‬

Building No. ‫رﻗﻢ اﻟﻤﺒﻨﻰ‬

Region Name ‫اﺳﻢ اﻟﻤﻨﻄﻘﺔ‬

City ‫وﺳﻴﻂ‬

Unit No. ‫رﻗﻢ اﻟﻮﺣﺪة‬

District Name ‫اﺳﻢ اﻟﺤﻲ‬

Street name ‫اﺳﻢ اﻟﺸﺎرع‬

Additional No. ‫اﻟﺮﻗﻢ ا‚ﺿﺎﻓﻲ‬

List of Principal Shareholders ‫ﻗﺎﺋﻤﺔ ﻛﺒﺎر اﻟﻤﺴﺎﻫﻤﻴﻦ اﻟﺮﺋﻴﺴﻴﻴﻦ‬

of the Organization Who Own %5 or More ‫ أو أﻛﺜﺮ‬٪٥ ‫ﻟﻠﺸﺮﻛﺔ اﻟﺬﻳﻦ ﻳﻤﺘﻠﻜﻮن‬
‫اﻟﺠﻨﺴﻴﺔ‬ ‫ﻧﺴﺐ اﻟﻤﻠﻜﻴﺔ‬ ‫ اﻟﺸﺮﻳﻚ‬/ ‫اﺳﻢ اﻟﻤﺴﺎﻫﻢ‬ #
Nationality Percentage of Ownership Shareholder / Partner Name
1
2
3
4
5

List of Board of Directors Names ‫ﻗﺎﺋﻤﺔ ﺑﺄﺳﻤﺎء أﻋﻀﺎء ﻣﺠﻠﺲ ا
دارة‬

‫اﻟﺠﻨﺴﻴﺔ‬ ‫ا‚ﺳﻢ‬
Nationality Name #
1
2
3
4
5
6

List of Top Management Names ‫ﻗﺎﺋﻤﺔ ﺑﺄﺳﻤﺎء ا
دارة اﻟﻌﻠﻴﺎ‬

‫اﻟﺠﻨﺴﻴﺔ‬ ‫اﻟﻤﻨﺼﺐ‬ ‫ا‚ﺳﻢ‬
Nationality Position Name Name #

1
2
3
4
 Authorized Signatory Details ‫ﻣﻌﻠﻮﻣﺎت ﻋﻦ اšﺷﺨﺎص اﻟﻤﻔﻮﺿﻴﻦ ﺑﺎﻟﺘﻮﻗﻴﻊ‬
‫اﻟﺠﻨﺴﻴﺔ‬ ‫اﻟﺒﺮﻳﺪ ا‚ﻟﻜﺘﺮوﻧﻲ‬ ‫رﻗﻢ اﻟﺠﻮال‬ ‫رﻗﻢ اﻟﻬﻮﻳﺔ‬ ‫اﻟﻤﻨﺼﺐ‬ ‫ا‚ﺳﻢ اﻟﺮﺑﺎﻋﻲ‬
Nationality Email Mobile No. ID No. Position Full Name #

1
2

If You Are Holding a :‫إذا ﻛﻨﺖ ذو ﻣﻨﺼﺐ ﺳﻴﺎﺳﻲ‬

Political Position, Please Specify: ‫ﻳﺮﺟﻰ ﺗﺤﺪﻳﺪ اﻟﻤﻨﺼﺐ‬
‫ﻛﺒﺎر اﻟﺘﻨﻔﻴﺬﻳﻴﻦ ﻓﻲ‬ ‫ﻣﺴﺆول ﺳﻴﺎﺳﻲ أو ﺣﻜﻮﻣﻲ‬
‫ﻻﻳﻨﻄﺒﻖ‬ ‫ﻣﺆﺳﺴﺔ ﻣﻤﻠﻮﻛﺔ ﻟﻠﺪوﻟﺔ‬ ‫أو ﻗﻀﺎﺋﻲ أو ﻋﺴﻜﺮي‬ ‫ﻣﺴﺆول ﺣﺰب ﺳﻴﺎﺳﻲ‬ ‫ﺳﺮة اﻟﺤﺎﻛﻤﺔ‬Ä‫ا‬
N/A Senior Executive in Political Governmental, Political Party Official Royal Family
Government-Owned Judicial or Military Official
Organization

Is Your Company Listed In ‫ﻫﻞ ﺷﺮﻛﺘﻜﻢ ﻣﺪرﺟﺔ ﻓﻲ‬

Saudi Stock Exchange Market ?(Tadawul) (‫اﻟﺴﻮق اﻟﻤﺎﻟﻲ اﻟﺴﻌﻮدي؟)ﺗﺪاول‬
‫ﻻ‬ ‫ﻧﻌﻢ‬
No Yes

Required Documents For Companies ‫اﻟﻮﺛﺎﺋﻖ اﻟﻤﻄﻠﻮﺑﺔ ﻟﻠﺸﺮﻛﺎت‬

Copy of Valid CR (‫ﻧﺴﺨﺔ ﻣﻦ اﻟﺴﺠﻞ اﻟﺘﺠﺎري )ﺳﺎري اﻟﺼﻼﺣﻴﺔ‬
Copy of VAT Certificate ‫ﻧﺴﺨﺔ ﻣﻦ ﺷﻬﺎدة اﻟﺘﺴﺠﻴﻞ ﻓﻲ ﺿﺮﻳﺒﺔ اﻟﻘﻴﻤﺔ اﻟﻤﻀﺎﻓﺔ‬
Copy of the ID of the Person Signing the Form and/or ‫ أو اﻟﻤﻔﻮض ﺑﺎﻟﺘﻮﻗﻴﻊ‬/ ‫ﻧﺴﺨﺔ ﻣﻦ ﻫﻮﻳﺔ اﻟﺸﺨﺺ اﻟﻤﻮﻗﻊ ﻋﻠﻰ اﻟﻨﻤﻮذج و‬
Authorized to Sign with Malath ‫ﻣﻊ ﻣﻼذ‬
Copy of National Address ‫ﻧﺴﺨﺔ ﻣﻦ اﻟﻌﻨﻮان اﻟﻮﻃﻨﻲ‬

Required Documents ‫اﻟﻮﺛﺎﺋﻖ اﻟﻤﻄﻠﻮﺑﺔ ﻟﻠﻬﻴﺌﺎت‬

for Nonprofit Organizations ‫واﻟﻤﺆﺳﺴﺎت ﻏﻴﺮ اﻟﺮﺑﺤﻴﺔ‬
Copy of the License Issued By A Relevant. Governmental ‫ﻧﺴﺨﺔ ﻣﻦ اﻟﺘﺮﺧﻴﺺ اﻟﺼﺎدر ﻋﻦ اﻟﺠﻬﺔ اﻟﺤﻜﻮﻣﻴﺔ ذات اﻟﻌﻼﻗﺔ‬
Authority. ‫ﺷﺨﺎص اﻟﺬﻳﻦ ﺳﻴﺘﻮﻟﻮن إﻗﺎﻣﺔ ﻋﻼﻗﺔ ﻋﻤﻞ‬Ä‫ﺗﻔﻮﻳﺾ ﻣﺠﻠﺲ ا‚دارة اﻟﻰ ا‬
Authorization Letter From The Board of Directors to the ‫ﻣﻊ ﺷﺮﻛﺔ ﻣﻼذ ﻟﻠﺘﺄﻣﻴﻦ‬
Persons Who Will Be Dealing with Malath Insurance. ‫ﺷﺨﺎص اﻟﻤﻔﻮﺿﻴﻦ‬Ä‫ﻧﺴﺨﺔ ﻣﻦ ﻫﻮﻳﺔ ا‬
Copy of Authorized Person’s ID.

Required Documents ‫اﻟﻮﺛﺎﺋﻖ اﻟﻤﻄﻠﻮﺑﺔ‬

for Government Sectors ‫ﻟﻠﻘﻄﺎﻋﺎت اﻟﺤﻜﻮﻣﻴﺔ‬
A Copy of All Required Documents According To The ‫ﻧﺴﺨﺔ ﻣﻦ ﺟﻤﻴﻊ اﻟﻮﺛﺎﺋﻖ اﻟﻤﻄﻠﻮﺑﺔ وﻓﻘﺎ ﻟﻨﻈﺎم اﻟﺠﻬﺔ اﻟﺤﻜﻮﻣﻴﺔ‬
Regulation and The Administrative Rules of The ‫وﺗﻨﻈﻴﻤﻬﺎ ا‚داري‬
Governmental Body
 Declaration / Consent
I declare that the documents submitted for
identification and all other information provided above
are true, accurate and complete. I further declare that
I do not have any other names or identification
particulars, apart from those submitted above.
I understand that the details provided by me are the
basis for which the terms of the policy apply, and I
shall notify MALATH immediately in writing of any
changes.
I hereby agree that I shall indemnify MALATH against
all and any loss arising from my misrepresentation
under these declarations and MALATH shall have the
right at its own discretion to reevaluate the coverage,
reject the claim and/ or investigate claims with no
legal liability towards them.
I declare that I do not have any relationship in any
criminal activity or money laundering & terrorism
financing and the paid insurance premiums are from
my legal income and have not been obtained by any
illegal activity, it is also known that the insurance
company has the right to cancel this policy in case it
has been provided with incorrect identity details or
misleading and inaccurate information.
I declare that I am fully aware of all the terms and
conditions of the insurance policy, which is explained
by the representatives of MALATH.
Customer Name
Authorized Signatory Name
Position
Date
Signature
Stamp
For Internal Use Only
(To Be Filled Out By MALATH Staff )
Verify That the Entire
Customer Data is Filled
Name
Date
Signature
‫ إﻗﺮار‬/ ‫إﻓﺼﺎح‬
‫أﺗﻌﻬﺪ ﺑﺄن اﻟﻮﺛﺎﺋﻖ اﻟﻤﻘﺪﻣﺔ ﻟﺘﺤﺪﻳﺪ اﻟﻬﻮﻳﺔ وﻛﺎﻓﺔ‬
،‫اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﺼﺮح ﺑﻬﺎ أﻋﻼه ﺻﺤﻴﺤﺔ ودﻗﻴﻘﺔ وﻛﺎﻣﻠﺔ‬
‫وأﻗﺮ أﻳﻀ„ ﺑﺄﻧﻪ ﻟﻴﺲ ﻟﺪي أي أﺳﻤﺎء أو ﺗﻔﺎﺻﻴﻞ ﻫﻮﻳﺔ أﺧﺮى ﻏﻴﺮ‬
‫ وأﺗﻔﻬﻢ أﻳﻀ„ ﺑﺄن اﻟﺘﻔﺎﺻﻴﻞ اﻟﻤﻘﺪﻣﺔ‬.‫ﺗﻠﻚ اﻟﻤﻘﺪﻣﺔ أﻋﻼه‬
‫ ﻛﻤﺎ ﺳﺄﻗﻮم‬،‫ﻣﻦ ﻗﺒﻠﻲ ﺳﻴﺆﺧﺬ ﺑﻬﺎ ﻃﻮال ﻓﺘﺮة اﻟﻮﺛﻴﻘﺔ‬
‫ وﺧﻄﻴ„ ﻋﻦ أي ﺗﻐﻴﻴﺮات‬Ð‫ﺑﺈﺧﻄﺎرﻛﻢ ﻓﻮر‬
‫أﻋﻮض ﻣﻼذ ﻋﻦ ﻛﻞ وأي‬ ّ ‫وﺑﺎﻟﺘﺎﻟﻲ ﻓﺈﻧﻨﻲ أواﻓﻖ ﻋﻠﻰ أن‬
.‫ﺧﺴﺎﺋﺮ ﻋﻦ ﺗﺤﺮﻳﻔﻲ أو ﻋﺪم ﺗﺼﺮﻳﺤﻲ ﻟﻬﺬه اﻟﻤﻌﻠﻮﻣﺎت‬
‫وﻓﻲ ﻫﺬه اﻟﺤﺎﻟﺔ ﻳﺤﻖ ﻟﺸﺮﻛﺔ ﻣﻼذ إﻋﺎدة ﺗﻘﻴﻴﻢ اﻟﺘﻐﻄﻴﺔ‬
‫ أو اﻟﺘﺤﻘﻴﻖ ﻓﻲ اﻟﻤﻄﺎﻟﺒﺎت ﺑﺪون أي ﻣﺴﺆوﻟﻴﺔ‬/ ‫اﻟﺘﺄﻣﻴﻨﻴﺔ و‬
‫ﻗﺎﻧﻮﻧﻴﺔ ﺗﺠﺎﻫﻬﺎ‬.
‫وأﻗﺮ ﺑﺄﻧﻪ ﻻ ﻋﻼﻗﺔ ﻟﻲ ﺑﺄي ﻧﺸﺎط إﺟﺮاﻣﻲ أو ﻏﺴﻞ أﻣﻮال‬
‫وﺗﻤﻮﻳﻞ إرﻫﺎب وأن أﻗﺴﺎط اﻟﺘﺄﻣﻴﻦ اﻟﻤﺪﻓﻮﻋﺔ ﻣﻦ ﻣﺼﺪر‬
‫دﺧﻠﻲ اﻟﻤﺸﺮوع وأﻧﻪ ﻟﻢ ﻳﺘﻢ ﻛﺴﺒﻬﺎ ﻣﻦ أي ﻧﺸﺎط ﻏﻴﺮ‬
‫ وﻣﻦ اﻟﻤﻌﻠﻮم أﻳﻀ„ أن ﺷﺮﻛﺔ اﻟﺘﺄﻣﻴﻦ ﺗﺤﺘﻔﻆ ﺑﺤﻖ‬،‫ﻗﺎﻧﻮﻧﻲ‬
‫إﻟﻐﺎء ﻫﺬه اﻟﻮﺛﻴﻘﺔ ﻓﻲ ﺣﺎل ﺗﺒ ّﻴﻦ أﻧﻪ ﻗﺪ ﺗﻢ ﺗﺰوﻳﺪﻫﺎ‬
‫ﺑﺘﻔﺎﺻﻴﻞ اﻟﻬﻮﻳﺔ ﺑﺸﻜﻞ ﻏﻴﺮ ﺻﺤﻴﺢ أو ﺗﻘﺪﻳﻢ ﻣﻌﻠﻮﻣﺎت‬
‫ﻣﻀﻠﻠﺔ وﻏﻴﺮ دﻗﻴﻘﺔ‬.
‫ﻛﻤﺎ أﻗﺮ ﺑﺈدراﻛﻲ اﻟﺘﺎم ﻟﺠﻤﻴﻊ ﺷﺮوط وأﺣﻜﺎم وﺛﻴﻘﺔ اﻟﺘﺄﻣﻴﻦ‬
‫اﻟﺘﻲ ﺗﻢ ﺷﺮﺣﻬﺎ ﻣﻦ ﻗﺒﻞ ﻣﻤﺜﻠﻲ ﺷﺮﻛﺔ ﻣﻼذ‬
‫اﺳﻢ اﻟﻌﻤﻴﻞ‬
‫اﺳﻢ اﻟﺸﺨﺺ اﻟﻤﻔﻮّ ض ﺑﺎﻟﺘﻮﻗﻴﻊ‬
‫اﻟﻤﻨﺼﺐ‬
‫اﻟﺘﺎرﻳﺦ‬
‫اﻟﺘﻮﻗﻴﻊ‬
‫اﻟﺨﺘﻢ‬
‫ﻟ´ﺳﺘﺨﺪام اﻟﺪاﺧﻠﻲ‬
(‫)ﺗﻌﺒﺄ ﻣﻦ ﻗﺒﻞ ﻣﻮﻇﻒ ﻣﻼذ‬
‫ﺗﻢ اﻟﺘﺄﻛﺪ ﻣﻦ ﺗﻌﺒﺌﺔ‬
ّ
‫ﻛﺎﻣﻞ ﺑﻴﺎﻧﺎت اﻟﻌﻤﻴﻞ‬
‫اﺳﻢ‬
‫اﻟﺘﺎرﻳﺦ‬
‫اﻟﺘﻮﻗﻴﻊ‬