‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ ‪Security Code /‬‬ ‫ﺭﻗﻢ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Number /‬‬

‫‪Liable Party Copy‬‬ ‫‪2001‬‬ ‫‪220010119315‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﺔ ﺍﻟﻘﺼﻴﺺ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪00:00:00.0 2020-11-12‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬
‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪2020-11-12‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪3‬‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪00:00:00.0‬‬ ‫‪Accident Date‬‬

‫ﻣﻌﺒﺪ ‪ -‬ﺟﺎﻑ‬ ‫ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ‬ ‫ﻻ ﻳﻮﺟﺪ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ‬ ‫‪16:48‬‬ ‫ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ‬
‫‪Road Condition‬‬ ‫‪Secondary Cause‬‬ ‫‪Accident Time‬‬

‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﻣﻨﻄﻘﺔ ‪232‬‬ ‫ﺍﻟﻤﻮﻗﻊ‬

‫ﻧﻬﺎﺭﺍ‬ ‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬
‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫ﺍﻟﻘﺼﻴﺺ‬ ‫‪Location‬‬

‫‪Affected Party Copy‬‬ ‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ ‪/‬‬ ‫‪Liable Party Copy‬‬ ‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﻳﺎﺳﺮ ﻣﺤﻤﺪ ﻳﻌﻘﻮﺏ ﻋﺒﺪﺍﻟﺤﻤﻴﺪ ﺍﻟﺘﻤﻴﻤﻲ‬ ‫‪ Driver Name‬ﻓﺮﺍﺱ ﺣﺴﺎﻥ ﺍﻟﻮﺭﻉ‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971508699123‬‬ ‫‪971507214888 Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪08/08/1977‬‬ ‫‪12/12/1900 Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺫﻛﺮ‬ ‫‪ Gender‬ﺫﻛﺮ‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﺍﻻﺭﺩﻥ‬ ‫‪ Nationality‬ﺳﻮﺭﻳﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪841421‬‬ ‫‪75165 License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺩﺑﻲ‬ ‫‪ License Issue Place‬ﺭﺍﺱ ﺍﻟﺨﻴﻤﺔ‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪13/12/2024‬‬ ‫‪14/01/2025 License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫‪-‬‬ ‫‪- Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫ﺍﻟﺸﺮﻛﺔ ﺍﻟﻮﻃﻨﻴﺔ ﻟﻠﺘﺄﻣﻴﻨﺎﺕ ﺍﻟﻌﺎﻣﺔ )ﺷﺮﻛﺔ ﻣﺴﺎﻫﻤﺔ ﻋﺎﻣﺔ(‬ ‫‪ Insurance Company‬ﺷﺮﻛﺔ ﺍﻟﻮﺛﺒﺔ ﺍﻟﻮﻃﻨﻴﺔ ﻟﻠﺘﺎﻣﻴﻦ‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫‪11MCS/20/00290‬‬ ‫‪40/9017/90/2019/20415 Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪13/05/2021‬‬ ‫‪30/01/2021 Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 91066‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪D‬‬ ‫‪ 78156 Plate Details‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪T‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﺍﺟﺮﻱ ﺯﻭﻥ ﻟﻠﺘﺠﺎﺭﺓ ﺵ‪.‬ﺫ‪.‬ﻡ‪.‬ﻡ‬ ‫‪ Owner Name‬ﻛﺮﻳﺴﺘﻰ ﻣﺎﻻﻳﻮ ﺗﻴﻠﻴﺞ‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - -TOYOTA - COROLLA‬ﺍﺑﻴﺾ ‪2014 -‬‬ ‫‪ - - MERCEDES Make-Model-Color-Year‬ﻓﻀﻲ ‪2001 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ‬
‫‪13/04/2021‬‬ ‫‪30/12/2020 Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬
‫ﺑﺴﻴﻄﺔ ‪ -‬ﺍﻟﻤﻘﺪﻣﺔ ﻭﺍﻟﻤﺆﺧﺮﺓ‬ ‫‪ Level of Damages‬ﺑﺴﻴﻄﺔ ‪ -‬ﺍﻟﻤﻘﺪﻣﺔ‬ ‫ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ‬

‫‪Damages Location‬‬ ‫ﺃﺿﺮﺍﺭ ﺍﻟﻤﺮﻛﺒﺔ‬

‫‪Accident Investigator‬‬ ‫ﺍﻟﻤﺤﻘﻖ ‪/‬‬ ‫‪Accident Diagram‬‬ ‫ﻣﺨﻄﻂ ﺍﻟﺤﺎﺩﺙ ‪/‬‬

‫)‪(0‬‬

‫‪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
 ‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ ‪Security Code /‬‬ ‫ﺭﻗﻢ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Number /‬‬
‫‪Liable Party Copy‬‬ ‫‪2001‬‬ ‫‪220010119315‬‬
‫ﻣﺮﻛﺰ ﺷﺮﻃﺔ ﺍﻟﻘﺼﻴﺺ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪00:00:00.0 2020-11-12‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬
‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪2020-11-12‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪3‬‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪00:00:00.0‬‬ ‫‪Accident Date‬‬

‫ﻣﻌﺒﺪ ‪ -‬ﺟﺎﻑ‬ ‫ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ‬ ‫ﻻ ﻳﻮﺟﺪ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ‬ ‫‪16:48‬‬ ‫ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ‬
‫‪Road Condition‬‬ ‫‪Secondary Cause‬‬ ‫‪Accident Time‬‬

‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﻣﻨﻄﻘﺔ ‪232‬‬ ‫ﺍﻟﻤﻮﻗﻊ‬

‫ﻧﻬﺎﺭﺍ‬ ‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬
‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫ﺍﻟﻘﺼﻴﺺ‬ ‫‪Location‬‬

‫‪Affected Party Copy‬‬ ‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ ‪/‬‬ ‫‪Liable Party Copy‬‬ ‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﻛﻤﺮﺍﻥ ﺧﺎﻥ ﺻﺎﺩﻕ ﺧﺎﻥ‬ ‫‪ Driver Name‬ﻓﺮﺍﺱ ﺣﺴﺎﻥ ﺍﻟﻮﺭﻉ‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971504564281‬‬ ‫‪971507214888 Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪01/01/1990‬‬ ‫‪12/12/1900 Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺫﻛﺮ‬ ‫‪ Gender‬ﺫﻛﺮ‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﺑﺎﻛﺴﺘﺎﻥ‬ ‫‪ Nationality‬ﺳﻮﺭﻳﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪3555958‬‬ ‫‪75165 License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺩﺑﻲ‬ ‫‪ License Issue Place‬ﺭﺍﺱ ﺍﻟﺨﻴﻤﺔ‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪27/08/2025‬‬ ‫‪14/01/2025 License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫‪-‬‬ ‫‪- Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫ﺷﺮﻛﺔ ﻋﻤﺎﻥ ﻟﻠﺘﺎﻣﻴﻦ )ﺵ ﻡ ﻉ(‬ ‫‪ Insurance Company‬ﺷﺮﻛﺔ ﺍﻟﻮﺛﺒﺔ ﺍﻟﻮﻃﻨﻴﺔ ﻟﻠﺘﺎﻣﻴﻦ‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫‪0102010101533946‬‬ ‫‪40/9017/90/2019/20415 Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪13/08/2021‬‬ ‫‪30/01/2021 Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 85357‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪H‬‬ ‫‪ 78156 Plate Details‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪T‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﺍﻧﻴﻞ ﺩﻫﻨﺮﺍﺝ ﺑﻮﺩﻫﺮﺍﻧﻲ‬ ‫‪ Owner Name‬ﻛﺮﻳﺴﺘﻰ ﻣﺎﻻﻳﻮ ﺗﻴﻠﻴﺞ‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - -TOYOTA - INNOVA‬ﻓﻀﻲ ‪2012 -‬‬ ‫‪ - - MERCEDES Make-Model-Color-Year‬ﻓﻀﻲ ‪2001 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ‬
‫‪13/07/2021‬‬ ‫‪30/12/2020 Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬
‫ﺑﺴﻴﻄﺔ ‪ -‬ﺍﻟﻤﺆﺧﺮﺓ‬ ‫‪ Level of Damages‬ﺑﺴﻴﻄﺔ ‪ -‬ﺍﻟﻤﻘﺪﻣﺔ‬ ‫ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ‬

‫‪Damages Location‬‬ ‫ﺃﺿﺮﺍﺭ ﺍﻟﻤﺮﻛﺒﺔ‬

‫‪Accident Investigator‬‬ ‫ﺍﻟﻤﺤﻘﻖ ‪/‬‬ ‫‪Accident Diagram‬‬ ‫ﻣﺨﻄﻂ ﺍﻟﺤﺎﺩﺙ ‪/‬‬

‫)‪(0‬‬

‫‪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