(‫إﺳــــﺘﻤــــﺎرة ﺣــــﺎدث ﻣــــﺮور )ﺑــــﺴﻴــــﻂ‬

MINOR ROAD TRAFFIC ACCIDENT FORM

Time: ‫وﻗﺖ اﻟﺤﺎدث‬ Date: ‫ﺗﺎرﻳﺦ اﻟﺤﺎدث‬

Accident Location: ‫ﻣﻮﻗﻊ اﻟﺤﺎدث‬

Type of Accident ‫ﻧــــﻮع اﻟﺤـــﺎدث‬

Collision against Collision between vehicles ‫إﺻﻄﺪام ﺑﻴﻦ ﻣﺮﻛﺒﺘﻴﻦ أو أﻛﺜﺮ‬ ‫إﺻﻄﺪام ﺑﺠﺴﻢ ﺛﺎﺑﺖ‬
a stationary object
Roll-over ‫ﺗﺪﻫﻮر‬

Details Second Party (Faulty Party) (‫اﻟﻄﺮف اﻟﺜﺎﻧﻲ )اﻟﻤﺘﺴﺒﺐ‬ First Party ‫اﻟﻄﺮف ا­ول‬ ‫اﻟﺒﻴﺎﻧﺎت‬

Vehicle No. ‫رﻗﻢ اﻟﻤﺮﻛﺒﺔ‬

Driver's Name ‫ﺳﺎﺋﻖ اﻟﻤﺮﻛﺒﺔ‬

Address / Tel. No. ‫ اﻟﻬﺎﺗﻒ‬/ ‫اﻟﻌﻨﻮان‬

Driving License No. / Category: ‫ اﻟﻔﺌﺔ‬/ ‫رﻗﻢ اﻟﺮﺧﺼﺔ‬

Sex / Nationality: ‫ اﻟﺠﻨﺲ‬/ ‫اﻟﺠﻨﺴﻴﺔ‬

Insurance Company: ‫ﺷﺮﻛﺔ اﻟﺘﺄﻣﻴﻦ‬

Type of Insurance: ‫ﻧﻮع اﻟﻮﺛﻴﻘﺔ‬

Insurance Policy No. ‫رﻗﻢ اﻟﻮﺛﻴﻘﺔ‬

Witness First Witness ‫اﻟﺸﺎﻫﺪ اﻟﺜﺎﻧﻲ‬ Second Witness ‫اﻟﺸﺎﻫﺪ ا­ول‬ ‫اﻟﺸﻬﻮد‬

Name ‫ا‹ﺳﻢ‬

Address ‫اﻟﻌﻨﻮان‬

Tel. No: ‫رﻗﻢ اﻟﻬﺎﺗﻒ‬

(‫اﻟﻤﺮﻛﺒﺔ اﻟﺜﺎﻧﻴﺔ )اﻟﻤﺘﺴﺒﺐ‬ ‫ا­ﺿـــﺮار ﺑـــﺎﻟـــﻤـــﺮﻛﺒـــــﺎت‬ ‫اﻟـــﻤـــﺮﻛﺒـــﺔ ا­وﻟـــﻰ‬

Second Vehicle (Faulty Driver) Damages to the Vehicle First Vehicle

Causes of Accident Sudden Hault ‫اﻟﻮﻗﻮف اﻟﻤﻔﺎﺟﻰء‬ ‫أﺳﺒﺎب اﻟﺤﺎدث‬

Over-speed No safety distance ‫ﻋﺪم ﺗﺮك ﻣﺴﺎﻓﺔ اﻣﺎن‬ ‫اﻟﺴﺮﻋﺔ‬

Negligence Wrong action ‫ﺳﻮء اﻟﺘﺼﺮف‬ ‫اﻫﻤﺎل‬

Fatigue Vehicle defects ‫ﻋﻴﻮب اﻟﻤﺮﻛﺒﺔ‬ ‫ارﻫﺎق‬

Overtaking Road defects ‫ﻋﻴﻮب اﻟﻄﺮﻳﻖ‬ ‫اﻟﺘﺠﺎوز‬

Weather Conditions Using GSM ‫اﻟﻬﺎﺗﻒ اﻟﻨﻘﺎل‬ ‫اﻟﻄﻘﺲ‬

‫ﺗﻮﻗﻴﻊ اﻟﻄﺮف اﻟﺜﺎﻧﻲ‬ ‫ﺗﻮﻗﻴﻊ اﻟﻄﺮف ا‹ول‬

Second Party Signature First Party Signature

For the use of Liva Insurance ‫”ﺳﺘﻌﻤﺎل ﺷﺮﻛﺔ ﻟﻴﭭﺎ ﻟﻠﺘﺄﻣﻴﻦ‬

The vehicle involved in the accident is ‫اﻟﻤﺮﻛﺒﺔ اﻟﻤﺘﺴﺒﺒﺔ ﻓﻲ اﻟﺤﺎدث ﻣﺆﻣﻨﺔ ﻟﺪﻳﻨﺎ ﺑﻤﻮﺟﺐ‬
insured with us vide Insurance Policy No.: :‫اﻟﻮﺛﻴﻘﺔ رﻗﻢ‬‫ر‬

Type of Insurance ‫ﻧﻮع اﻟﺘﺄﻣﻴﻦ‬

Claim No. ‫رﻗﻢ اﻟﻤﻄﺎﻟﺒﺔ‬

The Company will repair the damages as per the insurance policy. ‫ﺑﻤﻮﺟﺒﻪ ﺳﻮف ﺗﻘﻮم اﻟﺸﺮﻛﺔ ﺑﺈﺻﻼح اﻟﻤﺮﻛﺒﺔ اﻟﻤﺘﻀﺮرة‬
Therefore, technical opinion is required ‫ﻧﻄﻠﺐ رأﻳŸ ﻓﻨﻴŸ ﺣﻮل أﺳﺒﺎب اﻟﺤﺎدث‬

‫اﻟﺘﻮﻗﻴﻊ واﻟﺨﺘﻢ‬ ‫أﺳﻢ اﻟﻤﺨﻮل ﺑﺎﻟﺘﻮﻗﻴﻊ‬

Signature & Stamp Name of the Signatory

١٧٥٤٨٠٧ : ‫ت‬.‫ س‬،٢٤٧٦٦٨٠٠: ‫ ﻓﺎﻛﺲ‬،٢٤٧٦٦٨٠٠ : ‫ ﻫﺎﺗﻒ‬،‫ ﺳﻠﻄﻨﺔ ﻋﻤﺎن‬،‫ روي‬،١١٢ : ‫ اﻟﺮﻣﺰ اﻟﺒﺮﻳﺪي‬،١٤٦٣ : ‫ب‬.‫ ص‬، ‫ﺷﺮﻛﺔ ﻟﻴﭭﺎ ﻟﻠﺘﺄﻣﻴﻦ‬
info.om@livainsurance.com
www.livainsurance.om Liva Insurance, P.O. Box: 1463, Ruwi, PC: 112, Sultanate of Oman, Tel.:24766800, Fax: 24793582, C.R. No.: 1754807