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 in this 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 ID Number E-mail Postal Code 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/