Name of the Proposer










Insured's Estimated Value of the Vehicle without accessories:

Insured's Estimated Value of accessories:

List of accessories inside the motor vehicle:

Period of Insurance: From To
Type of Cover:Insurance against Third Party LiabilityInsurance against Loss, Damage and Third Party Liability (Comprehensive)

OPTIONS:(AT EXTRA PREMIUM)
1. Do you require Personal Accident cover for the Driver?
YesNo
2. Do you require Personal Accident cover for the Passenger/s?
YesNo
3. Do you require to have the vehicle repaired at Dealer's garage?
YesNo
4. Do you require extension to cover Oman?
YesNo
5. Do you require OIC Gold Roadside Assistance Service Program- Unlimited (GRASP)?
YesNo
6) Do you require Hire Car Benefit (Pvt. Cars Only)?
YesNo
7. Will the car be driven by persons aged below 25 years?
YesNo

ACCIDENT HISTORY:
How many accidents were you involved in over the last three years?
Of the above, how many were due to your fault?
Who were your previous insurers?