‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ‬ ‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ ‪Security Code /‬‬ ‫ﺭﻗﻢ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Number /‬‬

‫‪Affected Party Copy‬‬ ‫‪22000‬‬ ‫‪223010533918‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﻪ ﺍﻟﻘﺼﻴﺺ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪05/10/2023‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬

‫‪2‬‬ ‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪05/10/2023‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪Accident Date‬‬

‫ﻣﻌﺒﺪ ‪ -‬ﺟﺎﻑ‬ ‫ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ‬ ‫ﻻ ﻳﻮﺟﺪ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ‬ ‫‪18:33‬‬ ‫ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ‬
‫‪Road Condition‬‬ ‫‪Secondary Cause‬‬ ‫‪Accident Time‬‬

‫ﻟﻴﻼً ‪ -‬ﺍﻹﺿﺎﺀﺓ‬ ‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﺍﻟﻤﻮﻗﻊ‬

‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬ ‫ﺷﺎﺭﻉ ﺍﻻﻣﺎﺭﺍﺕ‬
‫ﻛﺎﻓﻴﺔ‬ ‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫‪Location‬‬

‫‪The Affected Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﻀﺮﺭ )( ‪/‬‬ ‫‪The Liable Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﺑﺎﻻﺷﺎﻧﺪﺭﺍﻥ ﻧﺎﺭﺍﻳﺎﻧﺎﻥ ﺳﻴﺘﺎﺭﺍﻣﺎﻥ ﻧﺎﺭﺍﻳﺎﻧﺎﻥ‬ ‫‪ Driver Name‬ﺳﻴﺪ ﻋﻮﻥ ﺭﺿﺎ ﺳﻴﺪ ﺿﻤﻴﺮ ﺍﻟﺤﺴﻦ‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971502061608‬‬ ‫‪971507766921 Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪17/05/1968‬‬ ‫‪01/02/1967 Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺫﻛﺮ‬ ‫‪ Gender‬ﺃﻧﺜﻰ‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﺍﻟﻬﻨﺪ‬ ‫‪ Nationality‬ﺑﺎﻛﺴﺘﺎﻥ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪1099291‬‬ ‫‪196178 License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺩﺑﻲ‬ ‫‪ License Issue Place‬ﻋﺠﻤﺎﻥ‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪26/09/2026‬‬ ‫‪03/08/2026 License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫‪-‬‬ ‫‪9007807759 Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫ﺭﻭﻳﺎﻝ ﺍﻧﺪ ﺻﻦ ﺍﻟﻼﻳﻨﺲ ﻟﻠﺘﺎﻣﻴﻦ)ﺍﻟﺸﺮﻕ ﺍﻻﻭﺳﻂ( ﺍﻟﻤﺤﺪﻭﺩﺓ ﺵ‪.‬ﻡ‪.‬ﺏ‪.‬ﻡ‬ ‫‪ Insurance Company‬ﻣﺠﻤﻮﻋﻪ ﺍﻟﺨﻠﻴﺞ ﻟﻠﺘﺎﻣﻴﻦ )ﺍﻟﺨﻠﻴﺞ( ﺵ ﻡ ﺏ ﻣﻘﻔﻠﺔ ﻓﺮﻉ ﺩﺑﻲ‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫)ﻓﺮﻉ ﺩﺑﻰ(‬
‫‪31147686‬‬ ‫‪3000297994 Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪03/12/2023‬‬ ‫‪10/10/2024 Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 45274‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪T‬‬ ‫‪ 52712 Plate Details‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪T‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﺑﺎﻻﺷﺎﻧﺪﺭﺍﻥ ﻧﺎﺭﺍﻳﺎﻧﺎﻥ ﺳﻴﺘﺎﺭﺍﻣﺎﻥ ﻧﺎﺭﺍﻳﺎﻧﺎﻥ‬ ‫‪ Owner Name‬ﺍﻛﺎﻭﺳﺘﻚ ﻟﺘﺮﻛﻴﺐ ﺍﻟﻤﻮﺍﺩ ﺍﻟﻌﺎﺯﻟﺔ ﻓﻲ ﺍﻷﺑﻨﻴﺔ ﻭﺍﻟﻤﻨﺸﺂﺕ ﺍﻟﻤﺪﻧﻴﺔ ﺵ ﺫ ﻡ ﻡ‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - -NISSAN - TIIDA‬ﻓﻀﻲ ‪2011 -‬‬ ‫‪ - -SUZUKI - ERTIGA Make-Model-Color-Year‬ﺭﻣﺎﺩﻱ ‪2017 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ‬
‫‪03/11/2023‬‬ ‫‪10/09/2024 Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬
‫ﺑﺴﻴﻄﺔ ‪ -‬ﻓﻲ ﺍﻟﺨﻠﻒ‬ ‫‪ Level of Damages‬ﺑﺴﻴﻄﺔ ‪ -‬ﻓﻲ ﺍﻟﻤﻘﺪﻣﻪ‬ ‫ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ‬

‫‪Damages Location‬‬ ‫ﺃﺿﺮﺍﺭ ﺍﻟﻤﺮﻛﺒﺔ‬

‫‪Accident Investigator‬‬ ‫ﺍﻟﻤﺤﻘﻖ ‪/‬‬ ‫‪Accident Diagram‬‬ ‫ﻣﺨﻄﻂ ﺍﻟﺤﺎﺩﺙ ‪/‬‬

‫)‪null) null‬‬

‫‪Stamp & Signature‬‬ ‫ﺍﻟﺨﺘﻢ ﻭ ﺍﻟﺘﻮﻗﻴﻊ ‪/‬‬

‫ﻫﺬﻩ ﺍﻟﺸﻬﺎﺩﺓ ﺻﺪﺭﺕ ﺍﻟﻜﺘﺮﻭﻧﻴﺎ ﻭ ﻻ ﺗﺤﺘﺎﺝ ﺇﻟﻰ ﺧﺘﻢ‬

‫ﻟﻠﺘﺄﻛﺪ ﻣﻦ ﺻﺤﺔ ﻫﺬﺍ ﺍﻟﺘﻘﺮﻳﺮ‪ ،‬ﻳﺮﺟﻰ ﺍﻟﺪﺧﻮﻝ ﻋﻠﻰ ﺧﺪﻣﺔ ﺍﻹﺳﺘﻌﻼﻡ ﻋﻦ ﺍﻟﻤﺴﺘﻨﺪﺍﺕ ﺍﻟﺼﺎﺩﺭﺓ ﻋﻠﻰ ﻣﻮﻗﻌﻨﺎ‬
‫‪http://www.dubaipolice.gov.ae‬‬

‫ﻣﻼﺣﻈﺎﺕ ﻫﺎﻣﺔ‪:‬‬
‫ﺗﻘﺪﻡ ﺗﻘﺎﺭﻳﺮ ﺗﻜﺎﻟﻴﻒ ﺗﺼﻠﻴﺢ ﻣﺮﻛﺒﺎﺕ ﺍﻷﻃﺮﺍﻑ ﺍﻟﻤﺘﻀﺮﺭﺓ ﺇﻟﻰ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‪ .‬ﻭ ﻓﻴﻲ ﺣﺎﻟﺔ ﻋﺪﻡ ﻗﺒﻮﻟﻬﺎ ﻣﻦ ﻗﺒﻞ ﺍﻟﺸﺮﻛﺔ ﺍﻟﻤﺨﺘﺼﺔ ﺗﺤﺎﻝ ﺇﻟﻰ ﺍﻟﺸﺮﻃﺔ ﻻﻋﺘﻤﺎﺩﻫﺎ‪.‬‬ ‫‪.1‬‬
‫ﻻ ﻣﺎﻧﻊ ﻣﻦ ﺗﺼﻠﻴﺢ ﺍﻷﺿﺮﺍﺭ ﺍﻟﺘﻲ ﺣﺼﻠﺖ ﻓﻲ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﻓﻲ ﺍﻟﺤﺎﺩﺙ ﺍﻟﻤﺪﻭﻧﺔ ﺗﻔﺎﺻﻴﻠﻪ ﺃﻋﻼﻩ‪.‬‬ ‫‪.2‬‬
‫ﻟﻐﺎﻳﺔ ﺍﻹﻋﺘﺮﺍﺽ ﻋﻠﻰ ﺍﻟﺘﻘﺮﻳﺮﻳﺮﺟﻰ ﺯﻳﺎﺭﺓ ﺍﻟﻤﺮﻛﺰ ﺍﻟﻤﻌﻨﻲ ﺧﻼﻝ ‪ 24‬ﺳﺎﻋﺔ‪.‬‬ ‫‪.3‬‬