‫إﻓﺎدة طرف ﺣﺎدث‬

Name: :‫اﻹﺳم‬ Case Number: :‫رﻗم اﻟﺣﺎدث‬

Phone: : ‫اﻟﺟوال‬

Describing the circumstances of the accident ‫وﺻف ﻛﯾﻔﯾﺔ وﻗوع اﻟﺣﺎدث‬

‫ﺗﺣدﯾد ﻣوﻗﻊ اﻟﺿرر‬ ‫اﻟرﺳم اﻟﺗﻘرﯾﺑﻲ ﻟﻠﺣﺎدث‬

Location of the damage Sketch of the accident

I’m Confirm that the above ‫ﺑﺄن‬ ‫أﻗر أﻧﺎ‬

information is complete and true. .‫اﻟﻣﻌﻠوﻣﺎت اﻟﻣذﻛورة أﻋﻼه ﻛﺎﻣﻠﺔ وﺻﺣﯾﺣﺔ‬
Date: Signature: :‫اﻟﺗوﻗﯾﻊ‬ :‫اﻟﺗﺎرﯾﺦ‬