ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ                                                  ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ Security Code /               ﺭﻗﻢ ﺍﻟﺘﻘﺮﻳﺮ Report Number /
Affected Party Copy                                                        42050                                225010242361
                                             ﻣﺮﻛﺰ ﺷﺮﻃﺔ ﺍﻟﻘﺼﻴﺺ                        ﺍﻟﻤﺮﻛﺰ         00:00:00.0 2025-04-09                              ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ Report Date /
                                                                                                                                                                     ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ
                     ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ                                                         ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ         2025-04-09               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              18:07              ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ
                            Road Condition                                                                  Secondary Cause                                   Accident Time
                               ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ                                                                     ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ              ﻣﻨﻄﻘﺔ 261                  ﺍﻟﻤﻮﻗﻊ
   ﻧﻬﺎﺭﺍ                                                                  ﺻﺪﻡ  -ﻣﺮﻛﺒﺔ
                                Visibility                                                                  Type of Accident          ﺍﻟﻤﺤﻴﺼﻨﺔ ﺍﻷﻭﻟﻰ             Location
     Affected Party Copy        ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ /                        Liable Party Copy       ﻧﺴﺨﺔ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ /
                            ﻋﺼﻤﺖ ﺑﺎﺗﺸﺎ ﻋﺒﺪﺍﻟﻮﻫﺎﺏ ﻋﺒﺪﺍﻟﻮﻫﺎﺏ                                                Driver Nameﻣﺤﻤﺪ ﺷﺎﻫﺪ ﻣﺤﻤﺪ ﺭﻓﻴﻖ                              ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ
                                             971529643565                                                 971544572717 Mobile Number                                  ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ
                                                08/02/1987                                                     24/11/1998 Age                                               ﺍﻟﻌﻤﺮ
                                                          ﺫﻛﺮ                                                             Genderﺫﻛﺮ                                         ﺍﻟﺠﻨﺲ
                                                         ﺍﻟﻬﻨﺪ                                                         Nationalityﺑﺎﻛﺴﺘﺎﻥ                                  ﺍﻟﺠﻨﺴﻴﺔ
                                                   4185581                                                        4794913 License No                                ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ
                                                          ﺩﺑﻲ                                                             License Issue Placeﺩﺑﻲ                 ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ
                                                19/10/2028                                                     02/10/2026 License Expiry Date                ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ
                                                             -                                               9010171770 Liable Party Fine No                  ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ
                        ﺷﺮﻛﺔ ﺩﺑﻲ ﻟﻠﺘﺄﻣﻴﻦ )ﺷﺮﻛﺔ ﻣﺴﺎﻫﻤﺔ ﻋﺎﻣﺔ(                                          Insurance Companyﺳﻜﻮﻥ ﻟﻠﺘﺄﻣﻴﻦ )ﻣﺴﺎﻫﻤﺔ ﻋﺎﻣﺔ(                    ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ
                              P609012024000000178                                                    0102010502460745 Policy No                                     ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ
                                                31/08/2025                                                     26/04/2026 Ins. Expiry Date                   ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ
                                      54867ﺩﺑﻲ ﺧﺼﻮﺻﻲ F                                                13958 Plate Detailsﺩﺑﻲ ﺧﺼﻮﺻﻲ R                                ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ
   ﺍﻟﺸﺮﻛﺔ ﺍﻟﻮﻃﻨﻴﺔ ﻟﺘﺎﺟﻴﺮ ﺍﻟﺸﺎﺣﻨﺎﺕ ﺍﻟﻌﺎﻣﺔ ﻓﺮﻉ ﻣﻦ ﺍﻟﺸﺮﻛﺔ ﺍﻟﻮﻃﻨﻴﺔ                                   Owner Nameﺩﺍﺭ ﺍﻟﻬﻼﻝ ﻟﻠﺨﺪﻣﺎﺕ ﺍﻟﻔﻨﻴﺔ ﺵ.ﺫ.ﻡ.ﻡ                            ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ
                                         ﻟﺘﺎﺟﻴﺮ ﺍﻟﺴﻴﺎﺭﺍﺕ ﺫ.ﻡ.ﻡ
  - - NISSAN-URVANﺍﺑﻴﺾ ﺍﺯﺭﻕ ﻣﻠﺼﻖ ﺇﻋﻼﻧﻲ 2023 -                                            - - TOYOTA-HIACE Make-Model-Color-Yearﺍﺑﻴﺾ 2009 -               ﺍﻟﻨﻮﻉ-ﺍﻟﻄﺮﺍﺯ-ﺍﻟﻠﻮﻥ-ﺍﻟﺴﻨﺔ
                                                31/07/2025                                                     26/03/2026 Reg. Expiry Date                    ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ
                                     ﺑﺴﻴﻄﺔ  -ﻓﺎﻟﺨﻠﻒ  +ﺍﻟﻤﻘﺪﻣﻪ                                                   Level of Damagesﺑﺴﻴﻄﺔ  -ﺍﻟﻤﻘﺪﻣﻪ                   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 ﺍﻟﻤﺘﻀﺮﺭ                                                   ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ Security Code /                  ﺭﻗﻢ ﺍﻟﺘﻘﺮﻳﺮ Report Number /
                      Affected Party Copy                                                         42050                                   225010242361
                                        ﻣﺮﻛﺰ ﺷﺮﻃﺔ ﺍﻟﻘﺼﻴﺺ                        ﺍﻟﻤﺮﻛﺰ         00:00:00.0 2025-04-09                                  ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ Report Date /
                                                                                                                                                                     ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ
                ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ                                                           ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ           2025-04-09                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              18:07                  ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ
                       Road Condition                                                                   Secondary Cause                                      Accident Time
                         ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ                                                                        ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ               ﻣﻨﻄﻘﺔ 261                    ﺍﻟﻤﻮﻗﻊ
   ﻧﻬﺎﺭﺍ                                                             ﺻﺪﻡ  -ﻣﺮﻛﺒﺔ
                           Visibility                                                                    Type of Accident           ﺍﻟﻤﺤﻴﺼﻨﺔ ﺍﻷﻭﻟﻰ               Location
     Affected Party Copy   ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ /                        Liable Party Copy       ﻧﺴﺨﺔ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ /
                        ﺧﻮﻟﻪ ﻋﻴﺴﻰ ﺳﻠﻄﺎﻥ ﻋﻴﺴﻰ ﺍﻟﺴﻮﻳﺪﻯ                                                  Driver Nameﻣﺤﻤﺪ ﺷﺎﻫﺪ ﻣﺤﻤﺪ ﺭﻓﻴﻖ                                  ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ
                                        971543110003                                                  971544572717 Mobile Number                                      ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ
                                           01/07/1970                                                      24/11/1998 Age                                                   ﺍﻟﻌﻤﺮ
                                                     ﺃﻧﺜﻰ                                                              Genderﺫﻛﺮ                                            ﺍﻟﺠﻨﺲ
                                                 ﺍﻻﻣﺎﺭﺍﺕ                                                           Nationalityﺑﺎﻛﺴﺘﺎﻥ                                      ﺍﻟﺠﻨﺴﻴﺔ
                                                385688                                                        4794913 License No                                    ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ
                                                     ﺩﺑﻲ                                                               License Issue Placeﺩﺑﻲ                    ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ
                                           30/12/2031                                                      02/10/2026 License Expiry Date                   ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ
                                                       -                                                  9010171770 Liable Party Fine No                     ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ
               ﺷﺮﻛﺔ ﻣﻴﺜﺎﻕ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻜﺎﻓﻠﻲ ﺵ ﻡ ﻉ ﻓﺮﻉ ﺩﺑﻲ                                        Insurance Companyﺳﻜﻮﻥ ﻟﻠﺘﺄﻣﻴﻦ )ﻣﺴﺎﻫﻤﺔ ﻋﺎﻣﺔ(                         ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ
                                          2423202719                                            0102010502460745 Policy No                                          ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ
                                           28/08/2025                                                      26/04/2026 Ins. Expiry Date                       ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ
                                93396ﺩﺑﻲ ﺧﺼﻮﺻﻲ B                                                  13958 Plate Detailsﺩﺑﻲ ﺧﺼﻮﺻﻲ R                                    ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ
                        ﺧﻮﻟﻪ ﻋﻴﺴﻰ ﺳﻠﻄﺎﻥ ﻋﻴﺴﻰ ﺍﻟﺴﻮﻳﺪﻯ                                        Owner Nameﺩﺍﺭ ﺍﻟﻬﻼﻝ ﻟﻠﺨﺪﻣﺎﺕ ﺍﻟﻔﻨﻴﺔ ﺵ.ﺫ.ﻡ.ﻡ                                 ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ
               - - MERCEDES-C300ﺍﺳﻮﺩ 2011 -                                         - - TOYOTA-HIACE Make-Model-Color-Yearﺍﺑﻴﺾ 2009 -                    ﺍﻟﻨﻮﻉ-ﺍﻟﻄﺮﺍﺯ-ﺍﻟﻠﻮﻥ-ﺍﻟﺴﻨﺔ
                                           28/07/2025                                                      26/03/2026 Reg. Expiry Date                        ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ
                  ﺑﺴﻴﻄﺔ  -ﺍﻟﺨﻠﻒ ﺑﺴﻴﻄﻪ  +ﺍﻻﺭﺑﺎﻙ ﻟﻠﻜﺮﺳﻲ                                                       Level of Damagesﺑﺴﻴﻄﺔ  -ﺍﻟﻤﻘﺪﻣﻪ                       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