Aljazira Takaful Ta’awuniis a member in Saudi Credit Bureau (SIMAH)

(‫اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ ﺗﻌﺎوﻧﻲ ﻋﻀﻮ ﻓﻲ اﻟﺸﺮﻛﺔ اﻟﺴﻌﻮدﻳﺔ ﻟﻠﻤﻌﻠﻮﻣﺎت اﻻﺋﺘﻤﺎﻧﻴﺔ )ﺳﻤﺔ‬

Motor Vehicle Claim Form Comprehensive ‫اﺳﺘﻤﺎرة ﻣﻄﺎﻟﺒﺔ ﺗﺄﻣﻴﻨﻴﺔ اﻟﻤﺮﻛﺒﺎت اﻟﺸﺎﻣﻞ‬
INSURANCE POLICY INFORMATION FOR THIS CLAIM (FOR OFFICIAL USE ONLY) (‫)ﻟﻼﺳﺘﻌﻤﺎل اﻟﺮﺳﻤﻲ ﻓﻘﻂ‬ ‫ﻣﻌﻠﻮﻣﺎت اﻟﺘﺄﻣﻴﻦ اﻟﺨﺎﺻﺔ ﺑﺎﻟﻤﻄﺎﻟﺒﺔ‬

‫رﻗﻢ اﻟﻮﺛﻴﻘﺔ‬ ‫ﻣﻜﺎن اﻟﺤﺎدث‬

Offcial Use Only

‫ﻟﻼﺳﺘﻌﻤﺎل اﻟﺮﺳﻤﻲ‬
Policy No. Accident Location
‫ﻧﺴﺒﺔ اﻟﻤﺴﺆوﻟﻴﺔ‬ ‫ﻧﻮع اﻟﺘﺄﻣﻴﻦ‬
100% 75% 50% 25% 0% Comprehensive ‫ﺷﺎﻣﻞ‬
Liability % Type of Insurance

1. CLAIMANT INFORMATION (PLEASE FILL THE FORM COMPLETELY) (‫)اﻟﺮﺟﺎء ﺗﻌﺒﺌﺔ اﻟﻨﻤﻮذج ﺑﺸﻜﻞ ﻛﺎﻣﻞ‬ ‫ ﻣﻌﻠﻮﻣﺎت اﻟﻤﻄﺎﻟﺒﺔ‬.١
‫رﻗﻢ ﺗﻘﺮﻳﺮ اﻟﺤﺎدث‬ Najm/‫ﻧﺠﻢ‬ ‫ﻣﺒﺎﺷﺮة اﻟﺤﺎدث ﻣﻦ ﻗﺒﻞ‬
Accident Report No. Others/‫أﺧﺮى‬ Accident Attend By

‫رﻗﻢ ﻟﻮﺣﺔ اﻟﻤﺮﻛﺒﺔ‬ Am/’‫ﺻﺒﺎﺣ‬

/ / ‫ﺗﺎرﻳﺦ اﻟﺤﺎدث‬
Plate No. PM/“‫ﻣﺴﺎء‬ Accident Date

‫رﻗﻢ ﻫﻮﻳﺔ اﻟﻤﺎﻟﻚ‬ ‫أﺳﻢ اﻟﻤﺎﻟﻚ‬

Owner Report No. Owner Name

‫رﻗﻢ اﻟﺠﻮال‬ ‫اﻟﺒﺮﻳﺪ اﻻﻟﻜﺘﺮوﻧﻲ‬

Mobile No. E-mail

‫رﻗﻢ ﻫﻮﻳﺔ ﻗﺎﺋﺪ اﻟﻤﺮﻛﺒﺔ‬ ‫ﺗﺎرﻳﺦ ﻣﻴﻼد اﻟﺴﺎﺋﻖ‬

Drive I.D No. Date of birth for Driver

‫اﻟﺴﺎﺋﻖ ﻫﻮ ﻣﺎﻟﻚ اﻟﺴﻴﺎرة‬

Name of Driver/‫أﺳﻢ اﻟﺴﺎﺋﻖ‬ No ‫ ﻻ‬Yes ‫ﻧﻌﻢ‬
Driver Same as Owner

‫ﻣﻤﺘﻠﻜﺎت‬ ‫وﻓﻴﺎت‬ ‫أﺻﺎﺑﺎت‬ ‫أﺿﺮار اﻟﻤﺮﻛﺒﺔ‬

Property Damage Death Injury Vehicle Damage ‫ﻧﻮع اﻟﻤﻄﺎﻟﺒﺔ‬
‫أﺧﺮى‬ ‫ﻛﻮارث ﻃﺒﻴﻌﻴﺔ‬ ‫ﺣﺮﻳﻖ‬ ‫ﺳﺮﻗﺔ‬ Type of Claim
Other Natural Disaters ( Flood etc ...) Fire Theft

2. DETAIL DESCRIPTION OF ACCIDENT ‫ وﺻﻒ ﺗﻔﺎﺻﻴﻞ اﻟﺤﺎدث‬.٢

‫( ﻇﻬﺎر ﻣﻨﻄﻘﺔ اﻟﻀﺮر ﻓﻲ اﻟﻤﺮﻛﺒﺔ ﺑﺴﺒﺐ اﻟﺤﺎدث‬x) ‫ﺿﻊ ﻋﻼﻣﺔ‬ ‫ﻳﺮﺟﻰ وﺻﻒ ﻛﻴﻔﻴﺔ وﻗﻮع اﻟﺤﺎدث‬
Mark (x) to show damage areas of Vehicle due to this Accident Please Describe the Accident in your own words

‫اﻟﺠﺎﻧﺐ ا
ﻳﺴﺮ‬ ‫اﻟﺠﺎﻧﺐ ا
ﻳﻤﻦ‬

LHS RHS

‫ﻣﺨﻄﻂ اﻟﺤﺎدث‬
Accident Diagram

‫اﻟﻤﺆﺧﺮة‬ ‫اﻟﻤﻘﺪﻣﺔ‬
Rear Front

3. ENCLOSURES ‫ اﻟﻤﺮﻓﻘﺎت‬.٣

‫ﺻﻮرة رﺧﺼﺔ ﻗﻴﺎدة اﻟﺴﺎﺋﻖ‬ ‫أﺻﻞ ﺗﻘﺮﻳﺮ اﻟﺤﺎدث واﻟﻜﺮوﻛﻲ‬

Copy of Driver’s License (Rukhsa) Original Accident Report
‫اﻟﺘﻘﺮﻳﺮ اﻟﻄﺒﻲ‬/‫اﻟﺼﻚ اﻟﺸﺮﻋﻲ‬ ‫أﺻﻞ أﻣﺮ ا®ﺻﻼح‬
Court Judgment/ Medical Report Original Repair Order
(‫ﺻﻮرة ﺷﻬﺎدة اﻟﺘﺄﻣﻴﻦ )ﻟﻠﻤﺆﻣﻦ ﻟﻪ‬ ‫ﺻﻮرة اﺳﺘﻤﺎرة اﻟﺴﻴﺎرة اﻟﻤﺆﻣﻦ ﻋﻠﻴﻬﺎ‬
Copy of Insurance Certificate Copy of Vehicle Registration (Istimara)
‫أﺧﺮى‬
Others

‫ﺧﺮ‬£‫ ﺗﻘﺪﻳﺮ ﺷﻴﺦ اﻟﻤﻌﺎرض ﻓﻲ ﺣﺎل وﺟﻮد ﻧﺴﺒﺔ ﻋﻠﻰ اﻟﻄﺮف ا‬/ ‫أﺻﻞ ﺛﻼث ﺗﻘﺪﻳﺮات اﻟﻮرش وأﺻﻞ ﺗﻘﺪﻳﺮ ﻗﻄﻊ اﻟﻐﻴﺎر‬

‫اﻟﻤﺴﺘﻨﺪات اﻟﻨﺎﻗﺼﺔ‬ ‫ﻻ‬ ‫ﻧﻌﻢ‬ ‫اﻟﻤﺴﺘﻨﺪات ﻣﻜﺘﻤﻠﺔ‬

*Repair will be authorized after reciept of claim documents and completion of required procedure. .‫@ﻳﺘﻢ اﻟﺘﻌﻤﻴﺪ ﺑﺎ®ﺻﻼح ﺑﻌﺪ إﺳﺘﻼم اﻟﻤﺴﺘﻨﺪات اﻟﻤﺬﻛﻮرة أﻋﻼه ﻛﺎﻣﻠﺔ و اﺳﺘﻜﻤﺎل ا®ﺟﺮاءات اﻟﻼزﻣﺔ‬
*The Insured can recieve the vehicle after paying the deductible & Depreciation as per policy. .‫@ﻳﺘﻢ اﺳﺘﻼم اﻟﻤﺮﻛﺒﺔ ﺑﻌﺪ دﻓﻊ ﻣﺒﻠﻎ اﻟﺘﺤﻤﻞ و اﻻﺳﺘﻬﻼك اﻟﻤﺤﺪد ﻓﻲ وﺛﻴﻘﺔ اﻟﺘﺄﻣﻴﻦ‬

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 Aljazira Takaful Ta’awuniis a member in Saudi Credit Bureau (SIMAH)
(‫اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ ﺗﻌﺎوﻧﻲ ﻋﻀﻮ ﻓﻲ اﻟﺸﺮﻛﺔ اﻟﺴﻌﻮدﻳﺔ ﻟﻠﻤﻌﻠﻮﻣﺎت اﻻﺋﺘﻤﺎﻧﻴﺔ )ﺳﻤﺔ‬

Motor Vehicle Claim Form Comprehensive ‫اﺳﺘﻤﺎرة ﻣﻄﺎﻟﺒﺔ ﺗﺄﻣﻴﻨﻴﺔ اﻟﻤﺮﻛﺒﺎت اﻟﺸﺎﻣﻞ‬
4. INSURED DECLARATION ‫ إﻗﺮار اﻟﻤﺆﻣﻦ ﻟﻪ‬.٤

I, the undersigned do herby declare that there is no other insurance policy ‫أﻗﺮ أﻧﺎ اﻟﻤﻮﻗﻊ أدﻧﺎه ﺑﺄﻧﻪ ﻟﻴﺴﺖ ﻫﻨﺎك أﻳﺔ وﺛﻴﻘﺔ ﺗﺄﻣﻴﻦ أﺧﺮى ﻳﻤﻜﻦ اﻟﺘﻌﻮﻳﺾ ﻣﻦ‬
underwhich I can be in demnified with respect to this accident or loss. I do ‫ ﻛﻤﺎ أﻗﺮ ﺑﺄن ﻫﺬه اﻟﺴﻴﺎرة ﻣﻠﻚ ﻟﻲ وأﻧﻪ‬،‫ﺧﻼﻟﻬﺎ ﻓﻴﻤﺎ ﻳﺘﻌﻠﻖ ﺑﻬﺬا اﻟﺤﺎدث أو اﻟﻀﺮر‬
further declare that I own this vehicle and that by registering this claim, I/we
‫ ﺣﻘﻮﻗﻨﺎ‬/‫أﺣﻠﻨﺎ ﺟﻤﻴﻊ ﺣﻘﻮﻗﻲ‬/‫ ﺑﺄﻧﻨﺎ ﻗﺪ أﺣﻠﺖ‬/ ‫ﻓﻲ ﺣﺎﻟﺔ ﻗﺒﻮل ﻫﺬه اﻟﻤﻄﺎﻟﺒﺔ ﺑﺄﻧﻨﻲ‬
subrogate all my/our rights arising of the accident detailed above to Aljazira
Takaful Ta’awuni Co. By virtue of this declaration I/we have waived the full ‫اﻟﻨﺎﺷﺌﺔ ﻋﻦ ﻫﺬا اﻟﺤﺎدث اﻟﻤﺬﻛﻮرة ﺑﻴﺎﻧﺎﺗﻪ أﻋﻼه إﻟﻰ ﺷﺮﻛﺔ اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ ﺗﻌﺎوﻧﻲ‬
sum of recovery entitled to me/ us against this loss and I/ we have no ‫ ﻟﻨﺎ ﻋﻦ ﻫﺬا اﻟﺤﺎدث وﻻﻣﺎﻧﻊ‬/‫وﺑﻬﺬا أﺗﻨﺎزل ﻋﻦ ﻛﺎﻣﻞ ﻣﺒﻠﻎ ا®ﺳﺘﺮداد اﻟﻤﺴﺘﺤﻖ ﻟﻲ‬
objection to pay all mounts and accruals arising of this accident to Aljazira ‫ ﻟﺪﻳﻨﺎ ﻣﻦ دﻓﻊ ﺟﻤﻴﻊ اﻟﻤﺒﺎﻟﻎ واﻟﻤﺴﺘﺤﻘﺎت اﻟﻨﺎﺷﺌﺔ ﻋﻦ ﻫﺬا اﻟﺤﺎدث إﻟﻰ ﺷﺮﻛﺔ‬/‫ﻟﺪي‬
Takaful Ta’awuni Co. as well as issuance of relevant cheques in its name ‫اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ ﺗﻌﺎوﻧﻲ وإﺻﺪار اﻟﺸﻴﻜﺎت ﺑﺈﺳﻤﻬﺎ وﺑﻨﺎء“ ﻋﻠﻰ ﻫﺬا ا®ﻗﺮار ﻓﺈﻧﻪ ﻻﻳﺤﻖ‬
based on this declaration.I/ We shall have no right, whatsoever, to claim this
.‫ﻟﻲ ﺑﺄي وﺟﻪ أو ﻓﻲ أي وﻗﺖ اﻟﻤﻄﺎﻟﺒﺔ ﺑﻬﺬا اﻟﻤﺒﻠﻎ‬
amount at any time.

Date: :‫اﻟﺘﺎرﻳﺦ‬

Signature: :‫اﻟﺘﻮﻗﻴﻊ‬

5. DRIVER DECLARATION ‫ إﻗﺮار اﻟﺴﺎﺋﻖ‬.٥

I, the undersigned do herby declare that, to the best of my knowledge and ،‫أﻗﺮ أﻧﺎ اﻟﻤﻮﻗﻊ أدﻧﺎه ﺣﺴﺐ ﻋﻠﻤﻲ اﻟﺘﺎم ﺑﺈن اﻟﺒﻴﺎﻧﺎت اﻟﻤﺪوﻧﺔ أﻋﻼه ﺣﻘﻴﻘﻴﺔ وﺻﺤﻴﺤﺔ‬
belief the particulars entered above are true and correct. I/we subrogate all /‫أﺣﻠﻨﺎ ﺟﻤﻴﻊ ﺣﻘﻮﻗﻲ‬/‫ ﺑﺄﻧﻨﺎ ﻗﺪ أﺣﻠﺖ‬/‫وإﻧﻪ ﻓﻲ ﺣﺎﻟﺔ ﻗﺒﻮل ﻫﺬه اﻟﻤﻄﺎﻟﺒﺔ ﺑﺄﻧﻲ‬
my/our rights arising of the accident detailed above to Aljazira Takaful
‫ﺣﻘﻮﻗﻨﺎ اﻟﻨﺎﺷﺌﺔ ﻋﻦ ﻫﺬا اﻟﺤﺎدث اﻟﻤﺬﻛﻮرة ﺑﻴﺎﻧﺎﺗﻪ أﻋﻼه إﻟﻰ ﺷﺮﻛﺔ اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ‬
Ta’awuni Co. By virtue of this declaration I/we have waived the full sum of
recovery entitled to me/ us against this loss and I/ we have no objection to ‫ ﻟﻨﺎ ﻋﻦ ﻫﺬا اﻟﺤﺎدث‬/‫ﺗﻌﺎوﻧﻲ وﺑﻬﺬا أﺗﻨﺎزل ﻋﻦ ﻛﺎﻣﻞ ﻣﺒﻠﻎ ا®ﺳﺘﺮداد اﻟﻤﺴﺘﺤﻖ ﻟﻲ‬
pay all mounts and accruals arising of this accident to Aljazira Takaful ‫إﻟﻰ ﺷﺮﻛﺔ اﻟﺠﺰﻳﺮة ﺗﻜﺎﻓﻞ ﺗﻌﺎوﻧﻲ وإﺻﺪار اﻟﺸﻴﻜﺎت ﺑﺈﺳﻤﻬﺎ وﺑﻨﺎء“ ﻋﻠﻰ ﻫﺬا ا®ﻗﺮار‬
Ta’awuni Co. as well as issuance of relevant cheques in its name based on .‫ﻓﺈﻧﻪ ﻻﻳﺤﻖ ﻟﻲ ﺑﺄي وﺟﻪ أو ﻓﻲ أي وﻗﺖ اﻟﻤﻄﺎﻟﺒﺔ ﺑﻬﺬا اﻟﻤﺒﻠﻎ‬
this declaration. I/ We shall have no right, whatsoever, to claim this amount
at any time.

Date: :‫اﻟﺘﺎرﻳﺦ‬

Signature: :‫اﻟﺘﻮﻗﻴﻊ‬

6. FOR COMPANY USE ONLY ‫ ﻟﻼﺳﺘﻌﻤﺎل ﻣﻦ ﻗﺒﻞ اﻟﺸﺮﻛﺔ ﻓﻘﻂ‬.٦

Notes: :‫ﻣﻼﺣﻈﺎت‬

Date/ Time ‫ اﻟﻮﻗﺖ‬/‫اﻟﺘﺎرﻳﺦ‬ Claim No. ‫إدﺧﺎل اﻟﻤﻄﺎﻟﺒﺔ ﺑﻮاﺳﻄﺔ‬

Depreciation ‫اﻻﺳﺘﻬﻼك‬ Recieved by ‫اﻟﻤﻮﻇﻒ اﻟﻤﺴﺘﻠﻢ‬

Signature ‫اﻟﺘﻮﻗﻴﻊ‬ Deductible ‫اﻟﺘﺤﻤﻞ‬

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