‫ﺑﻬﺬﺍ ﻧﺸﻬﺪ ﺑﺄﻧﻨﺎ ﺃﺻﺪﺭﻧﺎ ﻭﺛﻴﻘﺔ ﺗﺄﻣﻴﻦ ﻟﻠﺴﻴﺎﺭﺓ ﺍﻟﻤﻮﺻﻮﻓﺔ ﺃﺩﻧﺎﻩ ﻭﻓﻘﺎ ﻷﺣﻜﺎﻡ ﺗﺄﻣﻴﻦ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ‬

‫ﺍﻟﻤﺪﻧﻴﺔ ﺗﺠﺎﻩ ﺍﻟﻐﻴﺮ )ﺍﻟﻤﺮﻛﺒﺎﺕ( ﻓﻲ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬

This is to certify that a policy of insurance has been issued in respect of the
vehicle details below as per statutory third party liability requirements of the
kingdom of Saudi Arabia

CERTIFICATE OF MOTOR VEHICLE : ‫ﺷﻬﺎﺩﺓ ﺗﺄﻣﻴﻦ ﺍﻟﺴﻴﺎﺭﺓ ﺭﻗﻢ‬

INSURANCE NO : 20/VP/68570/0/0 20/VP/68570/0/0
INSURED NAME :FAYI MOHAMMED ASSIRI ‫ ﻓﺎﻳﻊ ﻣﺤﻤﺪ ﻋﺴﻴﺮﻱ‬:‫ﺇﺳﻢ ﺍﻟﻤﺆﻣﻦ ﻟﻪ‬
MOTOR VEHICLE DETAILS : : ‫ﺗﻔﺎﺻﻴﻞ ﺍﻟﺴﻴﺎﺭﺓ‬
Registration No : HNB 7575 ٧٥٧٥ ‫ ﺏ ﻥ ﻫــ‬: ‫ﺭﻗﻢ ﺍﻟﻠﻮﺣﺔ‬
Chassis No : 1GNSC6E00CR247814 1GNSC6E00CR247814 : ‫ﺭﻗﻢ ﺍﻟﻬﻴﻜﻞ‬
Make : Chevrolet-Gm TAHOE TAHOE GM ‫ ﺷﻴﻔﺮﻭﻟﻴﻪ‬: ‫ﻧﻮﻉ ﺍﻟﺴﻴﺎﺭﺓ‬
Year : 2012 ٢٠١٢ : ‫ﺍﻟﻤﻮﺩﻳﻞ‬
Custom Card ID : : ‫ﺭﻗﻢ ﺍﻟﺒﻄﺎﻗﺔ ﺍﻟﺠﻤﺮﻛﻴﺔ‬
PERIOD OF INSURANCE : : ‫ﻣﺪﺓ ﺍﻟﺘﺄﻣﻴﻦ‬
Commencement date : 10/02/1442 (H) ‫ﻫﺠﺮﻳﺔ‬ ١٤٤٢/٠٢/١٠ : ‫ﺗﺎﺭﻳﺦ ﺍﻹﺑﺘﺪﺍﺀ‬
Expiry date : 19/02/1443 (H) ‫ﻫﺠﺮﻳﺔ‬ ١٤٤٣/٠٢/١٩ : ‫ﻭﻳﻨﺘﻬﻲ ﻓﻲ‬
Corresponding to : From 27/09/2020 To 26/09/2021 19/02/1443 (H) 10/02/1442 (H)
Subject always to the Limits of Liability of 10,000,000 S.R. as ‫ ﺭﺱ ﺍﻟﻤﺒﻴﻨﺔ ﻓﻲ ﺍﻟﻮﺛﻴﻘﺔ ﻭﺍﻟﻨﺎﺗﺠﺔ‬١٠،٠٠٠،٠٠٠ ‫ﻭﺫﻟﻚ ﺿﻤﻦ ﺣﺪﻭﺩ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ‬
provided in the Policy arising out of the use of the insured Motor ‫ﻹﺳﺘﺨﺪﺍﻡ ﺍﻟﺴﻴﺎﺭﺓ‬
Vehicle within Saudi Arabia .
‫ﺍﻟﻤﺆﻣﻨﺔ ﺩﺍﺧﻞ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬
This Certificate is deemed to be a guarantee for payment for all
amounts which the Insured Owner and/or the Authorized Driver at
‫ﻭﺗﻌﺘﺒﺮ ﻫﺬﻩ ﺍﻟﺸﻬﺎﺩﺓ ﻛﻀﻤﺎﻥ ﻟﺪﻓﻊ ﻛﺎﻓﺔ ﺍﻟﻤﺒﺎﻟﻎ ﺍﻟﺘﻲ ﻳﻜﻮﻥ ﺍﻟﻤﺎﻟﻚ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﺃﻭ‬
the time of the accident shall become legally liable to pay as ‫ ﺍﻟﻮﻓﺎﺓ ﺃﻭ ﺍﻹﺻﺎﺑﺔ ﺍﻟﺒﺪﻧﻴﺔ ﺍﻟﺘﻲ ﺗﺤﺪﺙ ﻷﻱ ﺷﺨﺺ ﺑﻤﺎ ﻓﻲ ﺫﻟﻚ‬. 1
compensation for ‫ﺭﻛﺎﺏ ﺍﻟﺴﻴﺎﺭﺓ‬
(a) Death or bodily injury sustained by any person including ‫ ﺗﻠﻒ ﻣﻤﺘﻠﻜﺎﺕ ﺃﻱ ﻃﺮﻑ ﺛﺎﻟﺚ ﺧﺎﺭﺝ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﺆﻣﻨﺔ‬. 2
passengers of the vehicle
(b) Damage to third party property outside the Insured Vehicle
SIGNED : : ‫ﺍﻟﺘﻮﻗﻴﻊ‬

Gary M.Lewin ‫ ﻟﻴﻮﻳﻦ‬.‫ﺟﺎﺭﻱ ﻡ‬

Chief Executive Officer ‫ﺍﻟﺮﺋﻴﺲ ﺍﻟﺘﻨﻔﻴﺬﻱ‬

IMPORTANT
‫ﻣﻼﺣﻄﺎﺕ ﻫﺎﻣﺔ‬
1. This certificate of Insurance and Policy is valid only for the ‫ ﺇﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺘﺄﻣﻴﻦ ﻫﺬﻩ ﺻﺎﻟﺤﺔ ﻓﻘﻂ ﻟﻠﻤﺎﻟﻚ ﺍﻟﻤﺆﻣﻦ ﻟﻪ ﻭﺍﻟﺴﺎﺋﻖ ﺍﻟﻤﺨﻮﻝ ﻟﻪ‬. 1
Insured Owner and the authorized Driver at the time of ‫ﺑﺎﻟﻘﻴﺎﺩﺓ ﻓﻲ ﺣﺎﻟﺔ ﻭﻗﻮﻉ ﺣﺎﺩﺙ ﻭﻫﻲ ﻏﻴﺮ ﻗﺎﺑﻠﺔ ﻟﻠﺘﺤﻮﻳﻞ ﺑﺪﻭﻥ ﻣﻮﺍﻓﻘﺔ‬
Accident and is NOT transferable without prior consent ‫ﻣﺴﺒﻘﺔ ﻣﻦ ﻗﺒﻞ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
of the Insurance Company.
2. Any Accident must be notified to the Insurance . ‫ ﻋﻨﺪ ﻭﻗﻮﻉ ﺃﻱ ﺣﺎﺩﺙ ﻳﺠﺐ ﺇﺧﻄﺎﺭ ﺍﻟﺸﺮﻛﺔ ﻓﻮﺭﺍ‬. 2
Company immediately.

AXA Cooperative Insurance Company CR-No 1010271203 P.O.Box 753 Al ١١٤٢١ ‫ ﺍﻟﺮﻳﺎﺽ‬٧٥٣ ‫ ﺹ ﺏ‬١٠١٠٢٧١٢٠٣ : ‫ﺷﺮﻛﺔ ﺃﻛﺴﺎ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﺱ ﺕ‬,
Riyadh 11421, Kanoo Tower, King Abdul Aziz Road,2nd Floor, Al Riyadh, ‫ﺍﻟﻄﺎﺑﻖ ﺍﻟﺜﺎﻧﻲ‬،‫ ﺷﺎﺭﻉ ﺍﻟﻤﻠﻚ ﻋﺒﺪ ﺍﻟﻌﺰﻳﺰ‬،‫ﺑﺮﺝ ﻛﺎﻧﻮ‬
KSA. ٠٠٩٦٦ (١١) ٤٧٨٠٤١٨ : ‫ﻓﺎﻛﺲ‬
Telephone 8001160020 ٨٠٠١١٦٠٠٢٠ : ‫ﻫﺎﺗﻒ‬
Fax : 00966 (11) 4780418 www.axa-cooperative.com : ‫ﺍﻟﻤﻮﻗﻊ ﺍﻹﻟﻜﺘﺮﻭﻧﻲ‬
Email : motorclaims.reg-ksa@axa-cooperative.com motorclaims.reg-ksa@axa-cooperative.com : ‫ﺍﻟﺒﺮﻳﺪ ﺍﻻﻟﻜﺘﺮﻭﻧﻲ‬
Website :www.axa-cooperative.com ‫ ﻭﺗﺤﻤﻞ ﺭﺧﺼﺔ ﺗﺄﻣﻴﻦ ﺭﻗﻢ‬١٠١٠٢٧١٢٠٣ ‫ﺷﺮﻛﺔ ﻣﺴﺠﻠﺔ ﻓﻲ ﻭﺯﺍﺭﺓ ﺍﻟﺼﻨﺎﻋﺔ ﻭﺍﻟﺘﺠﺎﺭﺓ ﻟﻠﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﺑﺴﺠﻞ ﺗﺠﺎﺭﻱ ﺭﻗﻢ‬
TMN/25/20101 ‫ ﺻﺎﺩﺭﺓ ﻣﻦ ﻗﺒﻞ ﻣﺆﺳﺴﺔ ﺍﻟﻨﻘﺪ ﺍﻟﻌﺮﺑﻲ ﺍﻟﺴﻌﻮﺩﻱ‬.