‫‪A-RAJH-1-B-15-007‬‬

‫ﺟدول وﺛﯾﻘﺔ ﺗﺄﻣﯾن اﻟﻣرﻛﺑﺎت‬

‫ﺿد اﻟﻐﯾر‬

‫ﺑﯾﺎﻧﺎت اﻟوﺛﯾﻘﺔ‬
‫ﺗﺟﺎه اﻟﻐﯾر‬ ‫اﻟﻣﺳؤوﻟﯾﺔ ﺗﺟﺎه اﻟﻐﯾر ‪ /‬اﻟﺷﺎﻣل‬ ‫‪469187752211290‬‬ ‫رﻗم اﻟوﺛﯾﻘﺔ‬
‫ﺿد اﻟﻐﯾر‬ ‫اﻟﻣﻧﺗﺞ‬ ‫‪08/11/2022‬‬ ‫ﺗﺎرﯾﺦ ﺑدء اﻟوﺛﯾﻘﺔ‬
‫اﻟﻣﻣﻠﻛﺔ اﻟﻌرﺑﯾﺔ اﻟﺳﻌودﯾﺔ‬ ‫اﻟﻧطﺎق اﻟﺟﻐراﻓﻲ ﻟﻠﺗﻐطﯾﺔ‪:‬‬ ‫‪07/11/2023‬‬ ‫ﺗﺎرﯾﺦ اﻧﺗﮭﺎء اﻟوﺛﯾﻘﺔ‬
‫ﺑﯾﺎﻧﺎت اﻟﻣﺷﺗرك‬
‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬ ‫اﻟﻣﺎﻟك‬ ‫ﻓرد‬ ‫ﻧوع اﻟﻣﺎﻟك‬
‫اﻟﻘطﯾف‬ ‫ﻣدﯾﻧﺔ اﻹﻗﺎﻣﺔ‬ ‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬ ‫اﻻﺳم‬
‫‪28-03-1409‬‬ ‫ﺗﺎرﯾﺦ اﻟﻣﯾﻼد‬ ‫‪1057940114‬‬ ‫رﻗم اﻟﮭوﯾﺔ‪/‬اﻟﺳﺟل اﻟﺗﺟﺎري‬
‫‪alwaheed6605@gmail.com‬‬ ‫اﻟﺑرﯾد اﻹﻟﻛﺗروﻧﻲ‬ ‫‪0576665050‬‬ ‫رﻗم اﻟﺟوال‬
‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬ ‫اﻟﻣؤﻣن ﻋﻠﯾﮫ‬ ‫ﻓرد‬ ‫اﻟﻣﺎﻟك‬
‫ﻣﻌﻠوﻣﺎت اﻟﺳﺎﺋﻖ‬
‫ﻣدﯾﻧﺔ اﻹﻗﺎﻣﺔ‬ ‫رﻗم اﻟﮭوﯾﺔ‬ ‫ﺗﺎرﯾﺦ اﻟﻣﯾﻼد‬ ‫ﻧوع اﻟﺳﺎﺋﻖ )اﺳﺎﺳﻲ‪/‬إﺿﺎﻓﻲ(‬ ‫اﻻﺳم‬
‫اﻟﻘطﯾف‬ ‫‪1057940114‬‬ ‫‪28-03-1409‬‬ ‫اﺳﺎﺳﻲ‬ ‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬

‫ﺑﯾﺎﻧﺎت اﻟﻣرﻛﺑﺔ‬
‫‪Small Car 4 Doors‬‬ ‫ﻧوع ھﯾﻛل اﻟﻣرﻛﺑﺔ‬ ‫ﻛﺎﻣري‬ ‫طراز‪ /‬ﻣودﯾل اﻟﻣرﻛﺑﺔ‬ ‫ﺗوﯾوﺗﺎ‬ ‫ﻣﺎرﻛﺔ اﻟﻣرﻛﺑﺔ )اﻟﻌﻼﻣﺔ‬
‫اﻟﺗﺟﺎرﯾﺔ(‬
‫اﺳود‬ ‫ﻟون اﻟﻣرﻛﺑﺔ‬ ‫‪5‬‬ ‫ﻋدد اﻟﻣﻘﺎﻋد‬ ‫‪2017‬‬ ‫ﺳﻧﺔ اﻟﺻﻧﻊ‬
‫‪Private‬‬ ‫اﺳﺗﺧداﻣﺎت اﻟﻣرﻛﺑﺔ‬ ‫‪NA‬‬ ‫ﻣﺑﻠﻎ اﻟﺗﻐطﯾﺔ اﻟﺗﺄﻣﯾﻧﯾﺔ‬ ‫د ا ه ‪9585‬‬ ‫رﻗم اﻟﻠوﺣﺔ‬
‫رﻗم اﻟﺑطﺎﻗﺔ اﻟﺟﻣرﻛﯾﺔ‬ ‫‪903177510‬‬ ‫اﻟرﻗم اﻟﺗﺳﻠﺳﻠﻲ‬ ‫‪6T1BF4FK2HX681708‬‬ ‫رﻗم ھﯾﻛل اﻟﻣرﻛﺑﺔ‬
‫ﻣﻠﺧص ﻟﻠﺗﻐطﯾﺔ‬
‫ﺣدود اﻟﺗﻐطﯾﺔ‬ ‫ﻣﻧﺎﻓﻊ اﻟﺗﻐطﯾﺔ اﻟﺗﺄﻣﯾﻧﯾﺔ‬
‫ﺗﻐطﯾﺔ اﻟطرف اﻟﺛﺎﻟث ﺣﺗﻰ ‪ 10‬ﻣﻠﯾون ﷼‬ ‫ﺗﻐطﯾﺔ اﻟطرف اﻟﺛﺎﻟث ﺣﺗﻰ ‪ 10‬ﻣﻠﯾون ﷼‬
‫ﺗﻐطﯾﺎت ﺗﺄﻣﯾﻧﯾﺔ إﺿﺎﻓﯾﺔ )اﺧﺗﯾﺎرﯾﺔ(‬
‫ﺑﯾﺎﻧﺎت‬
‫اﻟﻣﺑﻠﻎ )ﺑﺎﻟ﷼ اﻟﺳﻌودي(‬ ‫اﻻﺳﺗﻘطﺎع )اﻟﺧﺻوﻣﺎت(‬
‫‪1116.13‬‬ ‫ﺻﺎﻓﻲ اﻻﺷﺗراك)ﺷﺎﻣل اﻟﺧﺻوﻣﺎت‪,‬ﺧﺻم ﻋدم وﺟود ﻣطﺎﻟﺑﺎت‪,‬اﻟﻌﻣوﻟﺔ(‬
‫‪124.00‬‬ ‫‪10.00 %‬‬ ‫ﺧﺻم ﺧﺎص‬ ‫ﺧﺻم اﻟﻣرﻛﺑﺎت اﻟﻣﺗﻌددة‬ ‫ﺧﺻم اﻟوﻻء‬ ‫اﻟﺧﺻوﻣﺎت‬
‫‪13‬‬ ‫اﻟﻣﺳﺗوى‬ ‫ﺧﺻم ﻋدم وﺟود ﻣطﺎﻟﺑﺎت‬
‫‪22.32‬‬ ‫‪2%‬‬ ‫اﻟﻌﻣوﻟﺔ‬
‫‪167.42‬‬ ‫‪15.00 %‬‬ ‫ﺿرﯾﺑﺔ اﻟﻘﯾﻣﺔ اﻟﻣﺿﺎﻓﺔ‬
‫‪1283.55‬‬ ‫ﻣﺟﻣوع اﻻﺷﺗراك )ﺻﺎﻓﻲ اﻻﺷﺗراك ‪ +‬ﺿرﯾﺑﺔ اﻟﻘﯾﻣﺔ اﻟﻣﺿﺎﻓﺔ(‬
‫ﻣﻌﻠوﻣﺎت إﺿﺎﻓﯾﺔ‬
‫‪ .1‬ﺗدﻓﻊ ﻛﺎﻣل ﻗﯾﻣﺔ ﻗﺳط اﻟﺗﺄﻣﯾن ﻣﻘدﻣﺎ و ﺑﺷﻛل ﺳﻧوي‬
‫‪ .2‬ﻟرﻓﻊ أي ﻣطﺎﻟﺑﺔ ﯾرﺟﻰ إرﻓﺎق ﺗﻘرﯾر ﻣن اﻟﺷرطﺔ ﺑﺎﻟﺣﺎﻟﮫ‬
‫‪ .3‬ﻓﻲ ﺣﺎل ﺗﻌوﯾض اﻟطرف اﻟﺛﺎﻟث ﻋن ﻣرﻛﺑﺔ ﺗم ﻗﯾﺎدﺗﮭﺎ ﻣن ﺷﺧص ﻋﻣره أﻗل ﻣن ‪ 18‬ﺳﻧﺔ ﻓﺈن ﺗﻛﺎﻓل اﻟراﺟﺣﻲ ﺗﺣﺗﻔظ ﺑﺣﻖ اﻟرﺟوع وﺗﺣﺻﯾل اﻟﺗﻌوﯾض ﻣن اﻟﻣؤﻣن ﻟﮫ ﻋدا إذا ﻣﺎﻛﺎن اﻟﻣؤﻣن ﻟﮫ ﻣدرج ﻓﻲ ﺟدول اﻟوﺛﯾﻘﺔ‪ .‬ﻛﻣﺎ ﯾﺣﻖ أﯾﺿﺎ ً ﻟﺗﻛﺎﻓل‬
‫اﻟراﺟﺣﻲ رﻓض ﻣطﺎﻟﺑﺔ اﺻﻼح ﻣرﻛﺑﺔ اﻟﻣؤﻣن ﻟﮫ ﻓﻲ ﺣﺎل ﻗﯾﺎدة ﺷﺧص ﻋﻣره أﻗل ﻣن ‪ 18‬ﺳﻧﺔ ﻟم ﯾدرج ﻓﻲ ﺟدول اﻟوﺛﯾﻘﺔ‬
‫‪ .4‬ﺟدول اﻟوﺛﯾﻘﺔ ﯾﺣﺗوي ﻋﻠﻰ ﻣﻠﺧص اﻟﺗﻐطﯾﺔ ﻓﻘط وﻟﻼطﻼع ﻋﻠﻰ اﻟﺷروط واﻷﺣﻛﺎم ﯾرﺟﻰ اﻻطﻼع ﻋﻠﻰ ﻣﺳﺗﻧدات اﻟوﺛﯾﻘﺔ وﻗراءﺗﮭﺎ ﺑﺗﻣﻌن ﻟﻠﺗﺄﻛد ﻣن ﻓﮭﻣك اﻟﺗﻐطﯾﺎت اﻟﻣﺗﺎﺣﺔ ﻟك واﻻﺳﺗﺛﻧﺎءات ﻣن اﻟﺗﻐطﯾﺔ واﻟﺗﻌرف ﻋﻠﻰ آﻟﯾﺔ رﻓﻊ ﻣطﺎﻟﺑﺔ‬
‫‪ .5‬ﺗم اﻋﺗﻣﺎد اﻟﺗﻐطﯾﺔ ﺑﻧﺎءاً ﻋﻠﻰ ﻣﻌﻠوﻣﺎت اﻟﺳﺎﺋﻖ واﻟﻣرﻛﺑﺔ وﻧوع اﺳﺗﺧدام اﻟﻣرﻛﺑﺔ اﻟﻣﻘدﻣﺔ ﻣن اﻟﻌﻣﯾل وﻓﻲ ﺣﺎل أن ﻣﻌﻠوﻣﺎت اﻟﻣرﻛﺑﺔ واﻟﺳﺎﺋﻖ ﻣﺧﺗﻠﻔﺔ ﻋن ﻣﺎذﻛر اﻟﻌﻣﯾل أو اﺳﺗﺧدام اﻟﻣرﻛﺑﺔ ﻋﻛس ﻣﺎ ذﻛره اﻟﻌﻣﯾل ﯾﻔﻘد اﻟﻌﻣﯾل اﻟﺗﻐطﯾﺔ‬
‫‪ .6‬ﺗﺎﻣﯾن اﻟﻣرﻛﺑﺔ ﺗم اﻛﺗﺗﺎﺑﮫ ﺑواﺳطﺔ ﺷرﻛﺔ ﺗﻛﺎﻓل اﻟراﺟﺣﻲ ﻟﻠﺗﺄﻣﯾن‬
‫‪ .7‬ﻗﯾﻣﺔ اﻟﺿرﯾﺑﺔ اﻟﻣﺿﺎﻓﺔ ﻋﻠﻰ اﻟوﺛﯾﻘﺔ ﺗم ﺗﺣﺻﯾﻠﮭﺎ ﺑﺎﻟﻧﯾﺎﺑﺔ ﻋن ﺣﻛوﻣﺔ اﻟﻣﻣﻠﻛﺔ اﻟﻌرﺑﯾﺔ اﻟﺳﻌودﯾﺔ ﺑﻧﺎءا ﻋﻠﻰ ﻗﺎﻧون اﻟﺿراﺋب اﻟﺻﺎدر ﻣن اﻟﮭﯾﺋﺔ اﻟﻌﺎﻣﺔ ﻟﻠزﻛﺎة واﻟدﺧل ﻓﻲ ﻋﺎم ‪ 1438‬ھـ‬

‫ﻟﻠﻣﺳﺎﻋدة واﻟﻣطﺎﻟﺑﺎت ﯾرﺟﻰ اﻟﺗواﺻل ﻋﺑر ﻗﻧوات اﻟﺗواﺻل اﻵﺗﯾﺔ‪:‬‬

‫‪ 920004414‬أو ‪011 4409666‬‬ ‫ﻟﺗﻘدﯾم ﻣطﺎﻟﺑﺔ ﺧﻼل ﺳﺎﻋﺎت اﻟﻌﻣل )ﻣﺎ ﻋدا أﯾﺎم اﻟﻌطل اﻟرﺳﻣﯾﺔ( ﻣن اﻟﺳﺎﻋﺔ اﻟﺛﺎﻣﻧﺔ ﺻﺑﺎﺣﺎ ﺣﺗﻰ اﻟﺛﺎﻟﺛﺔ ﻣﺳﺎء ‪ ،‬ﻣن اﻷﺣد إﻟﻰ‬
‫اﻟﺧﻣﯾس ﯾرﺟﻰ اﻻﺗﺻﺎل ﻋﻠﻰ‬
 ‫‪A-RAJH-1-B-15-007‬‬

‫ﺗﺄﻣﯾﻧﻲ‬ ‫اﻟﻔرع‬ ‫ﻣﺑﯾﻌﺎت اﻟﻣوﻗﻊ اﻹﻟﻛﺗروﻧﻲ‬ ‫اﻟﻘﻧﺎة‬

‫ﻣﻛﺎن اﻹﺻدار‬ ‫‪07/11/2022‬‬ ‫ﺗﺎرﯾﺦ اﻹﺻدار‬
‫رﻗم اﻟرﺧﺻﺔ‬ ‫أﺻدرت ﻣن ﻗﺑل‬
 A-RAJH-1-B-15-007

Policy Schedule – Motor Insurance

TPL

Policy Details
Policy # 469187752211290 Plan Type Third Party Liability
Start Date 08/11/2022 Product TPL
End Date 07/11/2023 Geographical Scope Kingdom of Saudi Arabia
Participant Details
Type Individual Owner ‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬
Name ‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬ City of Residence ‫اﻟﻘطﯾف‬
ID / CR # 1057940114 DOB 28-03-1409
Mobile # 0576665050 Email alwaheed6605@gmail.com
Owner Individual Insured ‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬
Driver Information
Name(s) Main/Additional DOB ID # City of Residence
‫ﻣوﺳﻰ ﯾوﺳف ﺑن ﻣوﺳﻰ اﻟوﺣﯾد‬ Main 28-03-1409 1057940114 ‫اﻟﻘطﯾف‬

Vehicle Details
Make ‫ﺗوﯾوﺗﺎ‬ Model ‫ﻛﺎﻣري‬ Body Type Small Car 4 Doors
Model Year 2017 No. of Seats 5 Color ‫اﺳود‬
Plate # 9585 ‫د ا ه‬ Sum Insured NA Vehicle Use Private
Chassis # 6T1BF4FK2HX681708 Sequence # 903177510 Custom ID
Summary of Cover
Benefit Limit
Third Party Liability up to 10 Million riyals Third Party Liability up to 10 Million riyals
Optional Cover(s)
Contribution Information
Description Amount (in SAR)
Net Contribution(Inclusive of Discount, NCD, Commissions) 1116.13
Discount - Loyalty Multi Vehicle Special 10.00 % 124.00
No Claims Discount (NCD) Level 13
Commission 2% 22.32
Value Added Tax (VAT) 15.00 % 167.42
Total Contribution (Net Contribution + VAT) 1283.55
Additional Information
1. Annual contribution must be fully paid in advance.
2. Every claim must be accompanied by a police report.
3. In case of third party liability claim whilst the insured vehicle is being driven by a person below 18 years of age, Al Rajhi Takaful reserves the right of recourse
upon indemnifying the third party, unless anyone below 18 years of age is stated in the policy schedule. Al Rajhi Takaful reserves the right to decline own
damage claims if any, whilst the insured vehicle is being driven by anyone whose age is below the age of the Main Driver or Additional Driver mentioned in the
policy schedule.
4. This Policy Schedule contains a Summary of Cover only. For full Terms & Conditions, please read the policy wording carefully, to ensure your understanding of
what is covered, what is not covered and what to do if you need to apply for a claim.
5. This policy is based on driver's & vehicle's information and Vehicle's use as provided. Excludes cover if Vehicle Use is different from what is mentioned in
Vehicle Details section.
6. This motor insurance is underwritten by Al Rajhi Company for Co-operative Insurance (ARCCI).
7. Value Added Tax (VAT) has been charged on behalf of the Government of the Kingdom of Saudi Arabia in accordance with the VAT Act announced by General
Authority of Zakat and Tax (GAZT) in H1438.

For any assistance and/or claims,

To report a Claim Working hours: (except public holidays) 8AM to 5PM, Sunday to Call 920004414 or 011 4409666
Thursday
 A-RAJH-1-B-15-007

Channel Websales Branch Tameeni

Date of Issue 07/11/2022 Place of Issue
Issued by License #