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

‫‪Liable Party Copy‬‬ ‫‪95077‬‬ ‫‪219010497454‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﺔ ﺍﻟﺒﺮﺷﺎﺀ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪07/04/2019‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬

‫‪2‬‬ ‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪07/04/2019‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪Accident Date‬‬

‫ﻣﻌﺒﺪ ‪ -‬ﺟﺎﻑ‬ ‫ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ‬ ‫ﻻ ﻳﻮﺟﺪ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ‬ ‫‪17:39‬‬ ‫ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ‬
‫‪Road Condition‬‬ ‫‪Secondary Cause‬‬ ‫‪Accident Time‬‬

‫ﻧﻬﺎﺭﺍ‬ ‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﻣﻨﻄﻘﺔ ﺍﻟﺒﺮﺷﺎﺀ‬ ‫ﺍﻟﻤﻮﻗﻊ‬
‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫‪Location‬‬

‫‪The Affected Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﻀﺮﺭ )( ‪/‬‬ ‫‪The Liable Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﻟﻴﻨﺎ ﻋﺒﺪﺍﻟﻤﻨﻌﻢ ﺳﻴﺪ ﺍﺣﻤﺪ ﻋﻔﻴﻔﻰ‬ ‫ﺭﻓﻴﻖ ﺍﻟﻠﻪ ﺩﺍﺭﻳﺎ ﺧﺎﻥ‬ ‫‪Driver Name‬‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971561133558‬‬ ‫‪567253382‬‬ ‫‪Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪12/12/1900‬‬ ‫‪04/04/1989‬‬ ‫‪Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺫﻛﺮ‬ ‫ﺫﻛﺮ‬ ‫‪Gender‬‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﻣﺼﺮ‬ ‫ﺑﺎﻛﺴﺘﺎﻥ‬ ‫‪Nationality‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪96885‬‬ ‫‪3703768‬‬ ‫‪License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺭﺍﺱ ﺍﻟﺨﻴﻤﺔ‬ ‫ﺩﺑﻲ‬ ‫‪License Issue Place‬‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪02/04/2024‬‬ ‫‪26/12/2026‬‬ ‫‪License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫ـــ‬ ‫‪9002644482‬‬ ‫‪Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫ﺷﺮﻛﺔ ﺍﻟﻮﺛﺒﺔ ﺍﻟﻮﻃﻨﻴﺔ ﻟﻠﺘﺎﻣﻴﻦ‬ ‫ﺷﺮﻛﻪ ﺩﺑﻰ ﻟﻠﺘﺎﻣﻴﻦ‬ ‫‪Insurance Company‬‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫‪40/9017/90/2018/3789‬‬ ‫‪105185347‬‬ ‫‪Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪19/06/2019‬‬ ‫‪21/10/2019‬‬ ‫‪Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 65825‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪M‬‬ ‫‪ 16135‬ﺃﺑﻮﻇﺒﻲ ﺧﺼﻮﺻﻲ ‪15‬‬ ‫‪Plate Details‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﻟﻴﻨﺎ ﻋﺒﺪﺍﻟﻤﻨﻌﻢ ﺳﻴﺪ ﺍﺣﻤﺪ ﻋﻔﻴﻔﻰ‬ ‫ﺷﻴﻔﺖ ﻟﻴﺴﻴﻨﺞ ﻟﺘﺎﺟﻴﺮ ﺍﻟﺴﻴﺎﺭﺍﺕ ﺫ ﻡ ﻡ ﻓﺮﻉ ﺍﺑﻮﻇﺒﻰ‬ ‫‪Owner Name‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - -KIA - SPORTAGE‬ﺭﻣﺎﺩﻱ ‪2014 -‬‬ ‫ﻧﻴﺴﺎﻥ ‪ - -‬ﺍﺑﻴﺾ ‪2016 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ ‪Make-Model-Color-Year‬‬

‫‪19/05/2019‬‬ ‫‪21/09/2019‬‬ ‫‪Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬

‫ﺑﺴﻴﻄﺔ ‪ -‬ﻓﻲ ﺍﻟﻤﺆﺧﺮﻩ‬ ‫ﺑﺴﻴﻄﺔ ‪ -‬ﻓﻲ ﺍﻟﻤﻘﺪﻣﻪ‬ ‫‪Level of Damages‬‬ ‫ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ‬

‫‪Damages Location‬‬ ‫ﺃﺿﺮﺍﺭ ﺍﻟﻤﺮﻛﺒﺔ‬

‫‪Accident Investigator‬‬ ‫ﺍﻟﻤﺤﻘﻖ ‪/‬‬ ‫‪Accident Diagram‬‬ ‫ﻣﺨﻄﻂ ﺍﻟﺤﺎﺩﺙ ‪/‬‬

‫)‪ (35324‬ﺍﻟﻌﺮﻳﻒ ﺍﻭﻝ ﻋﺎﺋﺸﻪ ﻣﺤﻤﺪ ﻳﻮﺳﻒ ﻋﻠﻰ ﺍﻟﺠﻨﺎﺣﻰ‬

‫‪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