Motor Insurance Proposal Form

           About You

Name

 Date of Birth:

Nationality

 Country of Residence
Email Contact Designation
Mobile No. Company Name (To consider your submission, please provide with your company name)
Telephone No. Driving license Issue date
P.O. Box No.    
Total No of Claims excluding Third Party Claims  Total loss claims if any
           About your Car

Make and Model

 Type of Body

Year 

No. of Seats Current Value Financed By

           Product and Optional Covers

  Comprehensive Cover       Third party only

 Personal Accident to Driver

Off Road Cover

 Yes   No Personal Accident to Passenger

Loading and Unloading

Unnamed Driver - Sport Vehilces
Loss Of Use Yes   No Agency Repair Yes   No Oman   Yes   No

           Required Documents

Passport Copy

Driving license Costum Papers Claims Experince Registration Card Copy

Other Details if any:
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