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1 Allied Cooperative Insurance Group (ACIG) شركة املجموعة املتحدة للتاأمني التعاوين ) أ سيج( Call us:

2 When completing this Proposal Form... - Please answer all questions giving full and complete answers. - If the space provided on the Proposal Form is insufficient, please use a separate signed and dated sheet in order to provide a complete answer to any question. - Please ensure that the Proposal Form is properly signed and dated. Name of Proposer: ID/Iqama.: Date of Birth (DD/MM/YYYY): Occupation: Nationality: Address: P. O. Box: City: Post Code: Tel. (home): Tel. (office): Ext. : Fax: Mobile: Address: Period of insurance required (Gregorian year): from: / / to: / / Address of private dwelling to which this is to apply: 1. Is the dwelling: A detached house A semi-detached house An apartment 2. Are the main building of brick, stone or concrete construction with roof of slate, tiles concrete, asphalt, or any entirely incombustible material? If NO, please provide details: 3. Are the premises in good state of repair? If NO, please provide details: 4. Is there any profession or business carried on in your premises? If YES, please provide details: 5. Is there any basement? 6. Numbers of Stories? Page 1 of 3

3 Sums to be Insured (Section I or Section II is compulsory) Please insert against each of the following the amount of insurance required or the words "NOT REQUIRED". If more than one dwelling, please show separate sums insured for each. Section I (Building excluding land value) SR Section II (Contents) SR Please provide list of items whose value exceeds 5% of Contents value or SR. 5,000 whichever is lower. (Please use additional sheets, if space provided is not sufficient).. Item Description Quantity Value (SR) tes: 1. Claims and settlement is based on the actual value of the property at the time of its loss or damage. Your above declared amounts should reflect this. 2. The amount of insurance on contents should include all household goods and personal effects (jewelries, furs and precious metals are excluded). 3. There is a single item limit of 5% of the Sum Insured on contents unless full details are given to ACIG and agreement obtained thereon. The Policy will cover you against fire, lightning, explosion, earthquake, riot, strike, malicious damage, storm, flood, impact and burst pipes but the following extensions (Section III) can be added against additional contribution. Section III (Extensions): Please indicate if you wish to include them: 5% of Contents Sum A. Burglary cover for contents if selected above Insured unless otherwise agreed by Company B. Liability to Third Parties SR 1,000,000 Combined Single Limit & aggregate C. Liability to Domestic Employees SR 100,000 maximum any one employee D. Death of Insured and/or Spouse SR 100,000 anyone person E. Accidental Loss / Damage of Personal Possessions SR 20,000 (anyone item maximum of SR 4,000) F. Accidental Breakage of Glass and Sanitary Ware SR 10,000 5% of Building Sum Insured G. Loss of rent / cost of alternative accommodation or 10% of Contents Sum Insured Have you sustained any loss or damage during the last 3 years which was or would have been covered under this form of insurance? Page 2 of 3

4 If YES, please give full particulars including the date, nature and amount of loss(es): Has any insurer declined to accept, cancelled, refused to continue or agreed to continue only on special terms any insurance for you? If YES, please give particulars: Are there any additional facts affecting the proposed insurance which should be disclosed to the Company? If YES, please give particulars: te: Please use additional sheets, if space provided is not sufficient. Declaration I/ We declare that the information given in this proposal and any attachment to it are true and correct and all information relevant to the decision and terms of insurance has been given. I /We hereby authorized the underwriter to give to or obtain from other insurers any information relating to insurance held by me/us or any claim in relation thereto. I/We agree that this proposal, together with any other information supplied by us shall from the basis of the insurance contract between us and Allied Cooperative Insurance Group (ACIG) The Allied Cooperative Insurance Group (ACIG) undertakes to deal with this information in strict confidence. te: Completing this proposal form does not mean acceptance of this risk unless approved by Allied Cooperative Group ACIG- Signature: Date: Page 3 of 3

5 Allied Cooperative Insurance Group (ACIG) شركة شركة شركة املجموعة املتحدة للتاأمني التعاوين ) أ سيج( ) أ سيج( ) أ سيج(