Schedule No.

(5) ‫ﺟﺪﻭﻝ ﺭﻗﻢ‬

Schedule of Details of the Insured Motor Vehicle in the Insurance Policy against
Loss, Damage and Third Party Liability
‫ ﻭﺍﻟﻤﺴﺆﻟﻴﺔ ﺍﻟﻤﺪﻧﻴﺔ‬،‫ﺟﺪﻭﻝ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﺆﻣﻦ ﻋﻠﻴﻬﺎ ﻓﻲ ﻭﺛﻴﻘﺔ ﺗﺄﻣﻴﻦ ﺍﻟﻔﻘﺪ ﻭﺍﻟﺘﻠﻒ‬
Ref Number : DP/01/1001/24/14590 DP/01/1001/24/14590 ‫ﺭﻗﻡ ﺍﻟﻣﺭﺟﻊ‬
Policy Number : 1114088221 1114088221 ‫ﺭﻗﻡ ﺍﻟﻭﺛﻳﻘﺔ‬
The term of insurance begins at 00:00 on ‫ﻣﻥ ﻳﻭﻡ‬: 00:00 ‫ )ﻣﺩﺓ ﺍﻟﺗﺄﻣﻳﻥ( ﺗﺑﺩﺃ ﻓﻲ ﺗﻣﺎﻡ ﺍﻟﺳﺎﻋﺔ‬:‫ﻓﺗﺭﺓ ﺍﻟﺗﻐﻁﻳﺔ‬
30/06/2024, and expires at 23:59 on 31/07/2025 31/07/2025 23:59 ‫ﺍﻟﺳﺎﻋﺔ‬ ‫ﻓﻲ‬ ‫ﻭﺗﻧﺗﻬﻲ‬
30/06/2024 Agreed upon premium:AED. 2,100.00 Including VAT ‫ ﺩﺭﻫﻡ ﻳﺷﻣﻝ ﺍﻟﺿﺭﻳﺑﺔ‬2,100.00 : ‫ﻗﺳﻁ ﺍﻟﺗﺄﻣﻳﻥ ﺍﻻﺟﻣﺎﻟﻲ‬

INSURANCE HOUSE Company declares that the Motor Vehicle detailed in this ‫ﺗﻘﺭ ﺷﺭﻛﺔ ﺩﺍﺭ ﺍﻟﺗﺄﻣﻳﻥ ﺑﺄﻥ ﺍﻟﻣﺭﻛﺑﺔ ﺍﻟﻭﺍﺭﺩﺓ ﺑﻳﺎﻧﺎﺗﻬﺎ ﻓﻲ ﻫﺫﺍ ﺍﻟﺟﺩﻭﻝ ﻣﺅﻣﻧﺔ ﻟﺩﻳﻬﺎ‬
below Schedule is insured with it according to the provision of this Policy. ‫ﻭﻓﻘﺎ ﻷﺣﻛﺎﻡ ﻫﺫﻩ ﺍﻟﻭﺛﻳﻘﺔ‬

VEHICLE DETAILS ‫ﺑﻳﺎﻧﺎﺕ ﺍﻟﻣﺭﻛﺑﺔ‬

‫ﻓﺋﺔ ﺍﻟﻣﺭﻛﺑﺔ‬ ‫ﻟﻭﻥ ﺍﻟﻣﺭﻛﺑﺔ‬ ‫ﻧﻭﻉ ﺍﻟﻣﺭﻛﺑﺔ‬ ‫ﺭﻗﻡ ﺍﻟﻠﻭﺣﺔ‬ ‫ﺑﻠﺩ ﺻﻧﻊ ﺍﻟﻣﺭﻛﺑﺔ‬
Motor Vehicle Classification Color Make & Model Plate Number Country of Manufacture

4wd/Station/SUV SILVER NISSAN-PATROL 90626 Japan

‫ﻋﺩﺩ ﺍﻟﺭﻛﺎﺏ ﻣﻊ ﺍﻟﺳﺎﺋﻖ‬ ‫ﻋﺩﺩ ﺍﻻﺳﻁﻭﺍﻧﺎﺕ‬ ‫ ﺍﻟﻭﺯﻥ‬/ ‫ﺍﻟﺣﻣﻭﻟﺔ‬ ‫ﺳﻧﺔ ﺍﻟﺻﻧﻊ‬ ‫ﺻﻔﺔ ﺍﻻﺳﺗﻌﻣـﺎﻝ‬ ‫ﺻﻔﺔ ﺍﻟﺗﺳﺟﻳﻝ‬
Seating Capacity No. of Cylinders Tonnage/Weight Manufacturing Year Purpose of Use Registration on Type

7 6 1918 2016 Personal Use Private

TB48102244 ‫ﺭﻗﻡ ﺍﻟﻣﺣﺭﻙ‬ JN8FY1NY8GX018789 ‫)ﺭﻗﻡ ﺍﻟﻬﻳﻛﻝ )ﺍﻟﺷﺎﺻﻲ‬

Engine Number Chassis Number

Sum Insured : AED 85000.00 ‫ ﺩﺭﻫﻡ‬85000.00 : ‫ﺍﻟﻘﻳﻣﺔ ﺍﻟﺗﻘﺩﻳﺭﻳﺔ ﻟﻠﻣﺭﻛﺑﺔ‬

Territorial Limits : Within United Arab Emirates ‫ ﺍﻹﻣﺎﺭﺍﺕ ﺍﻟﻌﺭﺑﻳﺔ ﺍﻟﻣﺗﺣﺩﺓ‬: ‫ﺍﻟﺣﺩﻭﺩ ﺍﻟﺟﻐﺭﺍﻓﻳﺔ‬
LIMIT OF LIABILITY The Company's maximum liability in respect of Paragragh (c) of ‫( ﻣﻥ ﺍﻟﻔﺻﻝ ﺍﻟﺛﺎﻧﻲ ﻋﻥ ﻣﻁﺎﻟﺑﺔ ﺃﻭ ﺟﻣﻠﺔ‬۱)‫ﺍﻟﺣﺩ ﺍﻷﻗﺻﻰ ﻟﻣﺳﺅﻭﻟﻳﺔ ﺍﻟﺷﺭﻛﺔ ﺑﺎﻟﻧﺳﺑﺔ ﻟﻠﻔﻘﺭﺓ )ﺝ( ﻣﻥ ﺍﻟﺑﻧﺩ‬ ‫ﺣﺩﻭﺩ ﺍﻟﻣﺳﺅﻭﻟﻳﺔ‬
Clause 1 of chapter II in respect of any claim or total claims arising ‫ ﺩﺭﻫﻡ‬3,500,000 ‫ﻣﻁﺎﻟﺑﺎﺕ ﻧﺷﺄﺕ ﻋﻥ ﺣﺎﺩﺙ ﻭﺍﺣﺩ ﻫﻭ ﻣﺑﻠﻎ‬
from one accident is AED 3,500,000.

Special Condition : :The Insured or his representative shall bear DHS 700.00 plus out of ‫ ﺩﺭﻫﻡ ﻣﻥ ﺍﻟﺗﻌﻭﻳﺽ ﺍﻟﻣﺳﺗﺣﻖ ﺑﻣﻭﺟﺏ ﺃﺣﻛﺎﻡ‬350 ‫ ﻣﻥ ﻳﺣﻝ ﻣﺣﻠﻪ ﻣﺑﻠﻎ‬700.00 ‫ ﻳﺗﺣﻣﻝ ﺍﻟﻣﺅﻣﻥ ﻟﻪ‬: ‫ﺷﺭﻭﻁ ﺧﺎﺻﺔ‬
imdemnity due in accordance with the terms and conditions of Section ‫ﺍﻟﻔﺻﻝ ﺍﻷﻭﻝ ﻣﻥ ﻫﺫﺓ ﺍﻟﻭﺛﻳﻘﺔ‬
I of the policy

Repair Condition : Non-Agency ‫ ﺧﺎﺭﺝ ﺍﻟﻭﻛﺎﻟﺔ‬: ‫ﺷﺭﻭﻁ ﺍﻹﺻﻼﺡ‬

Passengers covered as per IA Decision No. (25) of 2016 2016 ‫ ﻟﻌﺎﻡ‬25 ‫ﺗﻐﻁﻳﺔ ﺍﻟﺭﻛﺎﺏ ﺣﺳﺏ ﻗﺎﻧﻭﻥ ﻫﻳﺋﺔ ﺍﻟﺗﺄﻣﻳﻥ ﺭﻗﻡ‬
CONDITIONS, CLAUSES AND ANY EXTENSION OF COVERS AS PER ATTACHED DOCUMENTS ‫ﺍﻟﺷﺭﻭﻁ ﻭﺍﻟﺑﻧﻭﺩ ﻭ ﺃﻱ ﺗﻐﻁﻳﺎﺕ ﺍﺿﺎﻓﻳﺔ ﻛﻣﺎ ﻫﻲ ﻭﺍﺭﺩﺓ ﻓﻲ ﺍﻟﻣﻠﺣﻖ‬

Insured's Details ‫ﺑﻳﺎﻧﺎﺕ ﺍﻟﻣﺅﻣﻥ ﻟﻪ‬

insured's Name : AHMED KHALFAN SUBAIH ALI ALKAABI ‫ ﺍﺣﻣﺩ ﺧﻠﻔﺎﻥ ﺻﺑﻳﺢ ﻋﻠﻰ ﺍﻟﻛﻌﺑﻰ‬: ‫ﺍﺳﻡ ﺍﻟﻣﺅﻣﻥ ﻟﻪ‬
Bank Name : : ‫ﺍﺳﻡ ﺍﻟﺑﻧﻙ‬
Address : : ‫ﺍﻟﻌﻧﻭﺍﻥ‬
Email : : ‫ﺍﻟﺑﺭﻳﺩ ﺍﻻﻟﻛﺗﺭﻭﻧﻲ‬
PO Box No : : ‫ﺍﺍﻟﻌﻧﻭﺍﻥ ﺍﻟﺑﺭﻳﺩﻱ‬
Mobile No :971501600141 971501600141 : ‫ﺭﻗﻡ ﺍﻟﻬﺎﺗﻑ‬
Identification No :784199337319489 784199337319489 : ‫ﺭﻗﻡ ﻫﻭﻳﺔ ﺍﻟﻣﺅﻣﻥ ﻟﻪ‬

Issued By : Motor Underwriting Department ‫ ﻗﺳﻡ ﺗﺎﻣﻳﻥ ﺍﻟﻣﺭﻛﺑﺎﺕ‬: ‫ﻣﺭﻛﺯ ﺍﻹﺻﺩﺍﺭ‬

Issuance Date : 29/06/2024 29/06/2024 : ‫ﺗﺎﺭﻳﺦ ﺍﻹﺻﺩﺍﺭ‬

This is a Computer-Generated Document, and Hence No Signature is Required

‫ﺍﺳﻡ ﻭ ﺗﻭﻗﻳـﻊ ﺍﻟﻣﺅﻣﻥ ﻟﻪ ﺃﻭ ﻣــﻥ ﻳﻧﻭﺏ ﻋﻧـﻪ‬

Name and Signature of the Insured or their Representative

 ‫‪Supplement of additional coverages for policy No.‬‬ ‫‪1114088221‬‬ ‫ﻣﻠﺣﻖ ﺍﻟﺗﻐﻁﻳﺎﺕ ﺍﻹﺿﺎﻓﻳﺔ ﻟﻠﻭﺛﻳﻘﺔ ﺭﻗﻡ‬
‫‪The below additional Covers are included in this policy‬‬ ‫ﺍﻟﺗﻐﻁﻳﺎﺕ ﺍﻹﺿﺎﻓﻳﺔ ﺍﻟﺗﺎﻟﻳﺔ ﻣﺷﻣﻭﻟﺔ ﻓﻲ ﻫﺫﻩ ﺍﻟﻭﺛﻳﻘﺔ‬

‫‪Additional Cover‬‬ ‫ﺍﻟﺗﻐﻁﻳﺎﺕ ﺍﻹﺿﺎﻓﻳﺔ‬

‫‪PAB to Driver‬‬ ‫ﺗﻐﻁﻳﺔ ﺍﻟﺣﻭﺍﺩﺙ ﺍﻟﺷﺧﺻﻳﺔ ﻟﻠﺳﺎﺋﻖ‬

‫‪PAB to Passenger‬‬ ‫ﺗﻐﻁﻳﺔ ﺍﻟﺣﻭﺍﺩﺙ ﺍﻟﺷﺧﺻﻳﺔ ﻟﻠﺭﻛﺎﺏ‬

‫‪24/7 Road Side Assistance/IMC Contact No. 600575751‬‬ ‫ﻟﺧﺩﻣﺔ ﺍﻟﻣﺳﺎﻋﺩﺓ ﻋﻠﻰ ﺍﻟﻁﺭﻳﻖ ﻋﻠﻰ ﻣﺩﺍﺭ ﺍﻟﺳﺎﻋﺔ ﺍﻻﺗﺻﺎﻝ ﻋﻠﻰ )‪(600575751‬‬

‫‪Ambulance Cover‬‬ ‫ﺭﺳﻭﻡ ﺍﻻﺳﻌﺎﻑ‬

‫‪Storm, Tempest, Flood and Earthquake‬‬ ‫ﺗﻐﻁﻳﺔ ﺍﻟﻌﻭﺍﺻﻑ ‪ ،‬ﺍﻟﺯﻭﺍﺑﻊ‪ ،‬ﺍﻟﻔﻳﺿﺎﻧﺎﺕ ﻭﺍﻟﺯﻻﺯﻝ‬

‫‪Windshield Glass Damage Limit: AED 5,000/-‬‬ ‫ﺍﻋﻔﺎء ﻣﻥ ﺍﻟﺗﺣﻣﻝ ﺍﻻﺟﺑﺎﺭﻱ ﻋﻥ ﺣﺎﺩﺙ ﺗﺑﺩﻳﻝ ﺍﻟﺯﺟﺎﺝ ﺍﻻﻣﺎﻣﻲ ﺣﺗﻰ ‪ 5,000‬ﺩﺭﻫﻡ‬

‫‪Accidental Medical Expenses Limit: AED 5,000/-‬‬ ‫ﺗﻐﻁﻳﺔ ﺍﻟﻣﺻﺎﺭﻳﻑ ﺍﻟﻁﺑﻳﺔ ﺍﻟﻁﺎﺭﺋﺔ ﻭﺍﻟﻧﺎﺗﺟﺔ ﻋﻥ ﺣﺎﺩﺙ ﺳﻳﺭ ﺣﺗﻰ ‪ 5,000‬ﺩﺭﻫﻡ‬

‫‪Personal Effect Cover limit : AED 3,000/-‬‬ ‫ﺗﻐﻁﻳﺔ ﺍﻟﻣﻣﺗﻠﻛﺎﺕ ﺍﻟﺷﺧﺻﻳﺔ ﺣﺗﻰ ‪ 3,000‬ﺩﺭﻫﻡ‬

‫‪VALUE ADDED TAX “VAT” CLAUSE‬‬ ‫ﺷﺭﻁ ﺿﺭﻳﺑﺔ ﺍﻟﻘﻳﻣﺔ ﺍﻟﻣﺿﺎﻓﺔ‬

‫)‪This policy is subject to Federal Law No. 8/2017 on Value Added Tax(VAT‬‬ ‫ﻫﺫﺓ ﺍﻟﻭﺛﻳﻘﺔ ﺗﺧﺿﻊ ﻷﺣﻛﺎﻡ ﺍﻟﻘﺎﻧﻭﻥ ﺍﻷﺗﺣﺎﺩﻱ ﺭﻗﻡ ‪ ۸‬ﻟﺳﻧﺔ ‪ ۲۰۱۷‬ﺑﺷﺄﻥ ﺍﻟﻘﻳﻣﺔ ﺍﻟﻣﺿﺎﻓﻪ ﻭﺃﻱ ﺿﺭﺍﺋﺏ ﻗﺩ ﺗﻔﺭﺽ ﻣﻥ ﻗﺑﻝ ﺍﻟﺳﻠﻁﺎﺕ ﺍﻟﻣﺧﺗﺻﻪ‬
‫‪and any other taxes could be applied by the Government‬‬

‫‪Signature and Stamp of the Company‬‬ ‫ﺍﻟﺗﻭﻗﻳﻊ ﻭﺍﻟﺧﺗﻡ ﻋﻥ ﺍﻟﺷﺭﻛـــــﺔ‪:‬‬

‫‪Approved By: EMP‬‬