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

‫‪Affected Party Copy‬‬ ‫‪1012‬‬ ‫‪225010181880‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﺔ ﺍﻟﻤﻮﺍﻧﺊ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪00:00:00.0 2025-03-15‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬
‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪2025-03-15‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪2‬‬ ‫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 ‫‪14:32‬‬ ‫ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ‬
‫‪Road Condition‬‬ ‫‪Secondary Cause‬‬ ‫‪Accident Time‬‬

‫ﻧﻬﺎﺭﺍ‬ ‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﺷﺎﺭﻉ ﺍﻡ ﻫﺮﻳﺮ‬ ‫ﺍﻟﻤﻮﻗﻊ‬
‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫‪Location‬‬

‫‪Affected Party Copy‬‬ ‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ ‪/‬‬ ‫‪Liable Party Copy‬‬ ‫ﻧﺴﺨﺔ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﺱ ﻡ ﻋﻠﻰ ﺭﺍﺯ ﻣﺤﻤﺪ ﻣﻨﺠﻮﺭ ﺭﺣﻤﻦ‬ ‫‪ Driver Name‬ﻋﻠﻰ ﻣﻬﺮﺍﻥ ﻣﺤﻤﺪ ﻗﺎﺳﻢ‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971525443306‬‬ ‫‪971555973796 Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪13/08/1997‬‬ ‫‪15/10/2002 Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺫﻛﺮ‬ ‫‪ Gender‬ﺫﻛﺮ‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﺑﻨﻐﻼﺩﻳﺶ‬ ‫‪ Nationality‬ﺑﺎﻛﺴﺘﺎﻥ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪4685635‬‬ ‫‪4444264 License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺩﺑﻲ‬ ‫‪ License Issue Place‬ﺩﺑﻲ‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪29/04/2026‬‬ ‫‪06/05/2029 License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫‪-‬‬ ‫‪9010071052 Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫ﺷﺮﻛﺔ ﻗﻄﺮ ﻟﻠﺘﺄﻣﻴﻦ‬ ‫‪ Insurance Company‬ﺷﺮﻛﺔ ﺍﻟﻌﻴﻦ ﺍﻻﻫﻠﻴﺔ ﻟﻠﺘﺄﻣﻴﻦ )ﻓﺮﻉ ﺩﺑﻲ(‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫‪2220200009‬‬ ‫‪T3/301166439 Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪10/02/2026‬‬ ‫‪11/01/2026 Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 6701‬ﺩﺑﻲ ﺍﺟﺮﺓ ﺍﺟﺮﺓ‬ ‫‪ 30334 Plate Details‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪R‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﻣﺆﺳﺴﻪ ﺗﺎﻛﺴﻲ ﺩﺑﻲ‬ ‫‪ Owner Name‬ﺳﻜﺎﻱ ﻫﺎﻱ ﻟﻠﺴﻔﺮ ﻭﺍﻟﺴﻴﺎﺣﺔ‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - -HYUNDAI - SONATA‬ﺑﻴﺞ‪/‬ﺍﺣﻤﺮ ‪2024 -‬‬ ‫‪ - -TOYOTA - PREVIA Make-Model-Color-Year‬ﺍﺑﻴﺾ‪/‬ﻟﺆﻟﺆﻱ ‪2015 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ‬
‫‪03/01/2026‬‬ ‫‪11/12/2025 Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬
‫ﺑﺴﻴﻄﺔ ‪ -‬ﻣﻦ ﺍﻟﺨﻠﻒ‬ ‫‪ Level of Damages‬ﺑﺴﻴﻄﺔ ‪ -‬ﻣﻦ ﺍﻻﻣﺎﻡ‬ ‫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