Dubai National Insurance

Motor Insurance:
Proposal Form

(Please answer every question on this sheet to enable us provided you with our best quote)

Owner/Driver details

Name
Age
Nationality
Address : P.O.Box
Emirates
Tel
Mobile
E-mail
Driving License No.
Expiry Date
How many years have you had your U.A.E. Driving license ?
Any other driving license ?
How many years?
How long have you been driving?
How many accidents have you had
Existing insurance expiry date
Vehicles details
Reg. No.
Make
Type
Chassis No.
Model
Engine no.
No. of seats
Colour
Sum Insured

Coverage Options
Gold CoverSilver Cover
For how many accidents have you had
Including Personal Accident Benefits for Driver (Silver only)
Including Personal Accident Benefits for Passengers (silver only):
Agency repair
Others (specify)

Further Information
If you would like to know more about our Global Drive Scheme, please tick one of the following options:
I would like to speak over the phone with one of your representatives
I would like to arrange a meeting with one of your representatives
Please send me full details of cover by faxby mailby E-mail
Please send me a No obligation quotation
I/We further declare and agree that I have clearly understood the terms, conditions and scope of the coverage being offered by Dubai National Insurance & Reinsurance PSC and I/We hereby agree to accept the additional premiums and or deductible as applicable to the option chosen by me/us in this proposal.
Date

To be completed by the Company
Motor Premium
Agency repair Premium
Driver P.A. Premium (If Gold then 0)
Passengers P.A. Premium (If Gold then 0)
Total Premium
(This quotation is valid for a month from the date of submission)
Quoted by
Date

ALSO IN GLOBAL DRIVE
Technical Assistance
Worldwide Personal Assistance
Worldwide Luggage Assistance