THIRD PARTY CLAIM FORM

Information about Insured Car: Client Name:___________________________________

Car Model and Type:____________________________

Plate No.:______________________________________

Third Party Information: Claim filing date:________________________________

Date of Accident:________________________________

Name of car owner:______________________________

Car Model and Type:_____________________________

Plate No.:______________________________________

Applicant Name:________________________________

Contact Number:________________________________

To complete the claim, please submit the following documents: Accident Report

Accident Sketch

Three different repair quotations

Vehicle ownership documents

Car owner Driver license

Copy of Personal ID

Other if needed.

Note: The Company may, after review of the document, request for more information and/or document to consider the claim.

Bank Account details: Bank name:________________________________________________

Branch Name:______________________________________________

A/C Number:_______________________________________________

IBAN Number:______________________________________________

A/C Name:_________________________________________________

City:______________________________________________________

Swift Code:_________________________________________________

Amount of Compensation:___________________________ SR.

Based on the above, I hereby fully release ACE Arabia, their clients and anyone who is involved in the accident in a direct or

indirect way from their obligations. And confirm that I have received the full compensation on the damage done to me and to my

car including expenses and damages the physical, material and moral and I don’t have any claim against them or right or a lawsuit

related to the accident mentioned above and its results that may either occur in the present or future or that may happen later

known by me or unknown whatever kind or type it was. Third Party Signature: Date: