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

‫‪Affected Party Copy‬‬ ‫‪25112‬‬ ‫‪222010675056‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﻪ ﺍﻟﻘﺼﻴﺺ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪11/02/2022‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬

‫‪2‬‬ ‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪11/02/2022‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪Accident Date‬‬

‫ﻣﻌﺒﺪ ‪ -‬ﺟﺎﻑ‬ ‫ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ‬ ‫ﻻ ﻳﻮﺟﺪ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ‬ ‫‪12:42‬‬ ‫ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ‬
‫‪Road Condition‬‬ ‫‪Secondary Cause‬‬ ‫‪Accident Time‬‬

‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﻣﻨﻄﻘﺔ ‪232‬‬ ‫ﺍﻟﻤﻮﻗﻊ‬

‫ﻧﻬﺎﺭﺍ‬ ‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬
‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫ﺍﻟﻘﺼﻴﺺ‬ ‫‪Location‬‬

‫‪The Affected Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﻀﺮﺭ )( ‪/‬‬ ‫‪The Liable Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﺍﺭﻛﺎﻧﺠﻴﻼ ﺑﻴﻠﻤﻴﺮﺍ ﺩﻳﺴﻮﺯﺍ‬ ‫‪ Driver Name‬ﺍﻧﺎﻧﺪﻫﻮ ﺍﺳﻮﻛﺎﻥ ﺍﺳﻮﻛﺎﻥ‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971553360059‬‬ ‫‪971562758796 Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪15/06/1982‬‬ ‫‪Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺃﻧﺜﻰ‬ ‫‪ Gender‬ﺫﻛﺮ‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﺍﻟﻬﻨﺪ‬ ‫‪ Nationality‬ﺍﻟﻬﻨﺪ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪4155264‬‬ ‫‪2277542 License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺩﺑﻲ‬ ‫‪ License Issue Place‬ﺃﺑﻮﻇﺒﻲ‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪09/08/2023‬‬ ‫‪07/12/2026 License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫‪-‬‬ ‫‪9005471633 Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫‪ Insurance Company‬ﺭﻭﻳﺎﻝ ﺍﻧﺪ ﺻﻦ ﺍﻟﻼﻳﻨﺲ ﻟﻠﺘﺎﻣﻴﻦ)ﺍﻟﺸﺮﻕ ﺍﻻﻭﺳﻂ( ﺍﻟﻤﺤﺪﻭﺩﺓ ﺵ‪.‬ﻡ‪.‬ﺏ‪.‬ﻡ‬
‫ﻧﻮﺭ ﻟﻠﺘﻜﺎﻓﻞ ﺍﻟﻌﺎﻡ )ﺵ‪.‬ﻡ‪.‬ﻉ(‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫)ﻓﺮﻉ ﺩﺑﻰ(‬
‫‪02252162357‬‬ ‫‪30170254 Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪11/08/2022‬‬ ‫‪08/06/2022 Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 65793‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪D‬‬ ‫‪ 16684 Plate Details‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪G‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﺍﺭﻛﺎﻧﺠﻴﻼ ﺑﻴﻠﻤﻴﺮﺍ ﺩﻳﺴﻮﺯﺍ‬ ‫‪ Owner Name‬ﺍﺭﻭﻣﺎ ﺍﻧﺘﺮﻧﺎﺷﻴﻮﻧﺎﻝ ﻟﻤﻘﺎﻭﻻﺕ ﺍﻟﺒﻨﺎﺀ )ﺵ ﺫ ﻡ ﻡ(‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - -NISSAN - SUNNY‬ﻓﻀﻲ ‪2013 -‬‬ ‫‪ - -NISSAN - SENTRA Make-Model-Color-Year‬ﺑﻨﻲ ‪2015 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ‬
‫‪11/07/2022‬‬ ‫‪08/05/2022 Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬
‫ﺑﺴﻴﻄﺔ ‪ -‬ﺍﻟﻤﺆﺧﺮﺓ‬ ‫‪ Level of Damages‬ﺑﺴﻴﻄﺔ ‪ -‬ﺍﻟﻤﻘﺪﻣﺔ‬ ‫ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ‬

‫‪Damages Location‬‬ ‫ﺃﺿﺮﺍﺭ ﺍﻟﻤﺮﻛﺒﺔ‬

‫‪Accident Investigator‬‬ ‫ﺍﻟﻤﺤﻘﻖ ‪/‬‬ ‫‪Accident Diagram‬‬ ‫ﻣﺨﻄﻂ ﺍﻟﺤﺎﺩﺙ ‪/‬‬

‫)‪null) null‬‬

‫‪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