Schedule No. (5)
Schedule of Details of the Insured Motor Vehicle in the Insurance Policy against Loss and Damage
Details of Motor Vehicle
Country of Manufacture
Plate Number
Make, Model
and Color
Motor
Vehicle
Classification
Registration Type
Purpose of use
Manufacturing Year
Tonnage or Weight
Number of Passengers with Driver
Engine Number:
Chassis Number:
……………………….. Company declares that the Motor Vehicle detailed above inthis Schedule is insured with it according to the provisions of this Policy.
Issued By: Issuance Date:
Policy Number:
The term of insurance begins at …………. on …/…/….., and expires at …………. on …/…/…..
Agreed upon premium:
Issuance date: …/…/…..
Insured's Details
Company's Details
Insured's Name
:
Company's Name
:
Address
:
Address
:
E-mail
:
E-mail
:
Postal Address
:
Postal Address
:
Identification Number
:
Phone
:
Phone
:
Name and signature of the Insured or their representative:
Signature and stamp of the Company:
Motor Vehicle Insurance Application
Applicant's Details
Name according to ID
First
Second
Third
Family Name
Date of Birth
/ /
P.O. Box
Postal Code
ID Number
E-mail
Home Phone
Office Phone
Mobile
Address/Emirate
Profession
Employer
Driving License Number
Expiration Date
Trade Name (if any)
Commercial Register Number
Head Office
Insurance Service Details
Registration Mark
Truck
Small Truck
Large Truck
Other
Model/Use
Private
Commercial
Rental
Driving Education
Other
Body Number
Engine Number
Chassis Number
Engine Capacity (CC)
No. of Passengers
Manufacturing Year
Current Value without Accessories
Current Value, including Accessories (to be elaborated)
Insurance Period
Insurance Type
Insured/Representative
Signature
/Stamp: Insurance Authority/