Motor Cycle Proposal Form

Insured's Estimated Value of the Vehicle without accessories:*

Insured's Estimated Value of accessories:*

List of accessories inside the motor vehicle:*

From*

To*

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

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

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?