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

‫‪Liable Party Copy‬‬ ‫‪92910‬‬ ‫‪220010964135‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﻪ ﺍﻟﻤﻮﺍﻧﺊ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪31/05/2020‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬

‫‪2‬‬ ‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪30/05/2020‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪Accident Date‬‬

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

‫ﻧﻬﺎﺭﺍ‬ ‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﺷﺎﺭﻉ ‪130‬‬ ‫ﺍﻟﻤﻮﻗﻊ‬
‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫‪Location‬‬

‫‪The Affected Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﻀﺮﺭ )‪/ (1‬‬ ‫‪The Liable Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﻭﺳﺎﻡ ﻳﺎﺳﺮ ﺷﻮﻣﺎﻥ‬ ‫ﺍﻟﺒﺮﺕ ﺑﺎﺳﻜﻮﺍ ﺗﺎﻛﻮﺩ‬ ‫‪Driver Name‬‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971503538507‬‬ ‫‪971567541308‬‬ ‫‪Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪10/04/1986‬‬ ‫‪30/11/1978‬‬ ‫‪Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺫﻛﺮ‬ ‫ﺫﻛﺮ‬ ‫‪Gender‬‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﺳﻮﺭﻳﺎ‬ ‫ﺍﻟﻔﻠﺒﻴﻦ‬ ‫‪Nationality‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪1877799‬‬ ‫‪1826284‬‬ ‫‪License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺩﺑﻲ‬ ‫ﺩﺑﻲ‬ ‫‪License Issue Place‬‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪27/02/2023‬‬ ‫‪18/09/2022‬‬ ‫‪License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫ـــ‬ ‫‪9003560977‬‬ ‫‪Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫ﺷﺮﻛﺔ ﺍﻟﺒﺤﻴﺮﺓ ﺍﻟﻮﻃﻨﻴﺔ ﻟﻠﺘﺄﻣﻴﻦ )ﻓﺮﻉ ﺩﺑﻲ(‬ ‫ﺫﻱ‪ .‬ﻧﻴﻮ‪ .‬ﺍﻧﺪﻳﺎ ﺍﺷﻮﺭﻧﺲ ﻛﻮﻣﺒﺎﻧﻲ ﻟﻴﻤﺘﺪ‬ ‫‪Insurance Company‬‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫‪SH922438‬‬ ‫‪C/493167/813‬‬ ‫‪Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪26/12/2020‬‬ ‫‪01/06/2021‬‬ ‫‪Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﺑﻴﺼﺔ‬
‫‪ 59038‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪F‬‬ ‫‪ 25386‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪O‬‬ ‫‪Plate Details‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﻭﺳﺎﻡ ﻳﺎﺳﺮ ﺷﻮﻣﺎﻥ‬ ‫ﺍﻟﺒﺮﺕ ﺑﺎﺳﻜﻮﺍ ﺗﺎﻛﻮﺩ‬ ‫‪Owner Name‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - - HONDA CITY‬ﺍﺣﻤﺮ ‪2010 -‬‬ ‫‪ - - FORD FIGO‬ﺍﺣﻤﺮ ‪2013 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ ‪Make-Model-Color-Year‬‬

‫‪26/11/2020‬‬ ‫‪01/05/2021‬‬ ‫‪Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬

‫ﺑﺴﻴﻄﺔ ‪ -‬ﺍﺿﺮﺍﺭ ﻓﻲ ﺍﻟﻤﻮﺧﺮﺓ ﻟﻠﻤﺮﻛﺒﻪ‬ ‫ﺑﺴﻴﻄﺔ ‪ -‬ﺍﺿﺮﺍﺭ ﻓﻲ ﺍﻟﻤﻘﺪﻣﺔ‬ ‫‪Level of Damages‬‬ ‫ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ‬

‫‪Damages Location‬‬ ‫ﺃﺿﺮﺍﺭ ﺍﻟﻤﺮﻛﺒﺔ‬

‫‪Accident Investigator‬‬ ‫ﺍﻟﻤﺤﻘﻖ ‪/‬‬ ‫‪Accident Diagram‬‬ ‫ﻣﺨﻄﻂ ﺍﻟﺤﺎﺩﺙ ‪/‬‬

‫)‪ (5568‬ﺍﻟﺮﻗﻴﺐ ﻋﺒﺪﺍﻟﺤﻜﻴﻢ ﻋﻮﺽ ﻫﻴﺜﻢ ﺍﻟﺴﻌﺪﻱ‬

‫‪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 ﻓﻲ 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 ﺯﻳﺎﺭﺓﺍﻟﻤﺮﻛﺰ ﺍﻟﻤﻌﻨﻲ ﺧﻼﻝ ‪ 24‬ﺳﺎﻋﺔ‪.‬‬ ‫‪.3‬‬