| Abu Dhabi National Takaful Co. P.S.C

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USER INFORMATION

Source Type

Partner Code

Customer Code

Division

Department

INSURED INFORMATION

Insured Code

First Name

Insured Client Code

Takaful Motor Insurance: Vehicle Information

Chassis Number

Vehicle Make

Vehicle Model

Body Type

Year of Make

Brand New

Yes No

Date of First Reg - (As per Mulkhiya)

Value of Vehicle

Vehicle Usage

Number of Cylinders

Number of Seats (including driver)

Import Y/N

Yes No

Imported Country

Is First Time Reg YN

Yes No

Agency Y/N

Yes No

INSURED/DRIVER INFORMATION

Insured Type

First Name

Last Name

AML Class

Passport No

Commercial No

Mobile Number

Date of Birth

Age

Driver same as Insured

Yes No

Driver Name

Driver Dob

Age

How many years without any accident?

Can you provide proof of no claims from your previous insurer

Yes No

Previous Policy Type

Is Your Current Policy Still Valid ?

Yes No

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Premium Additional Info

SummGrossPremium
SummNetPremium
SummAddlDiscount
SummAddlLoading
SummCharges
SummCommission
SummDeductible
SummTplLimit
SummVatOnPrem
SummVatOnComm
SummCommCode

SummNetToCustomer

Contribution Summary

Fields in red color are mandatory *

Your Reference No

Product

Value(AED)

Contribution (AED)

Charge

Commission(AED)

Vat On commission 5%

Deductible

VAT 5%

Total Contribution (AED)

Information Summary

Vehicle

Body Type

Year of Make

Brand New

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More Vehicle Info...

Trim

CC

Transmission

Vehicle Usage

Cylinder

Region

Driver + Passengers

Import Y/N

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Policy Start Date

Policy End Date

Emirates ID

VAT TRN Number

Trade License No

Trade License Issuing Authority

Trade License Issue Date

Trade License Expiry Date

Address

PO Box

Street name

City

Emirate

Occupation

Married

Yes No

Previous Policy Number

Previous Policy Expiry Date

TC No

Nationality

Gender

Male Female

Previous Claim YN

Yes No

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Engine Number

Chassis Number

Place of Registration

Registration Number

Vehicle Color 1

Vehicle Color 2

Vehicle Color 3

Mortgage Bank

Driving License No

License Issue Emirates

Loc By Emirates

License Issue Date

License Expiry Date

Driver License No

Driver License Issue Dt

DriverLicense Expiry Dt

Driver Emirates Id

Mulkiya Expiry Dt

Number of Doors

Horse Power

Fuel Type

Tonnage

Payment Mode

Vehicle Mileage

Mortgage Reference

Mortgage Description

Weight Empty

Weight Full

Vehicle Origin

RTA Transaction Type

Plate Category

TCF Issue Emirates

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Mulkiya Front

Mulkiya Back

Driving License Front

Driving License Back

Emirates Id - Front

Emirates Id - Back

No claim certificate

Purchase invoice

Information Summary

Fields in red color are mandatory *

Reference No

Contribution (AED)

VAT 5%

Product

Value(AED)

Deductible

+

More Vehicle Info...

Age

Vehicle

Body Type

Year of Make

Brand New

Trim

CC

Transmission

Region

Vehicle Usage

Cylinder

Driver + Passengers

Import Y/N

Motor Insurance

USER INFORMATION

INSURED INFORMATION

Takaful Motor Insurance: Vehicle Information

Takaful Motor Insurance: Vehicle Information

INSURED/DRIVER INFORMATION

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Premium Additional Info

Premium Summary

Contribution Summary

Information Summary

PLEASE ENTER FEW MORE DETAILS ABOUT YOU

PLEASE ENTER FEW MORE DETAILS ABOUT VEHICLE

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Information Summary