Motor Protection proposal

Data of Insurer requset

Name of Insured
Name of Benficairy
Age
Business or profession
Phone No.
Mobile No.
Address
E-mail
Insurance period

From
To
Place of Survey
Vehicle data required for insurance

Make & Modle
Year of Make
Type of body
Engine Capacity ( C.C)
Chassis No.
Engine No.
Registered Letters & Numbers
Number of authorized passengers
Estimate of present value ( Sum Insured )
Indicate the type of cover required

Comperhensive specified risk
YesNo
Third party liability insurance only
YesNo
Amount of insurance
Fire and theft in the case of disabled cars / or in a public or private garage
YesNo
Amount of insurance
Would you like to make additional insurance for an extra premium ?

Personal Accedint Driver
YesNo
Amount of insurance
Personal Accedint Passengar
YesNo
Amount of insurance
Is driving by anyone other than you?
YesNo
If yes, please mentioned his Name
Are you insured now or inured on any vehicle before?
YesNo
If yes, please mentioned the Name of Co. & date
Have any of the insurance companies refused or canceled your insurance or refused renewal or increased the value of the premium at the end of the term of insurance?
The number of years of driving within or outside the Arab Republic of Egypt?
Do you have another vehicle insured by Royal Insurance Co. ?
YesNo
Important Note:

The Insurance is not valid until the company accepts the insurance application and paid the permium

Undertaking

I am the undersigned wishing to make insurance in accordance with the terms of the policy issued by Royal Insurance Egypt and acknowledge that all data and information

The above is correct and identical to the reality and I did not hide from the company any statement of the data concerning the risk to be insured

The insurance application shall be accompanied by a copy of the identity card of the insured.

Signature
Date
Head Office: 48 Mohy El Din Abou El Ezz street – Dokki, GiZa , Egypt
Postal code: 12311
Phone No.: 202 – 33312999
Fax: 202 – 37609685