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

‫‪Affected Party Copy‬‬ ‫‪60500‬‬ ‫‪223010529431‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﻪ ﺍﻟﻘﺼﻴﺺ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪03/10/2023‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬

‫‪2‬‬ ‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪03/10/2023‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪Accident Date‬‬

‫ﻣﻌﺒﺪ ‪ -‬ﺟﺎﻑ‬ ‫ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ‬ ‫ﻻ ﻳﻮﺟﺪ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ‬ ‫‪19:29‬‬ ‫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 )( ‪/‬‬
‫ﺳﻴﺪ ﺷﺎﺩﺍﺏ ﺣﺴﻴﻦ ﺳﻴﺪ ﺍﻓﻀﻞ ﺣﺴﻴﻦ‬
‫‪971564743297‬‬
‫‪20/12/1990‬‬
‫ﺫﻛﺮ‬
‫ﺑﺎﻛﺴﺘﺎﻥ‬
‫‪3839334‬‬
‫ﺩﺑﻲ‬
‫‪03/07/2025‬‬
‫‪-‬‬
‫ﺷﺮﻛﺔ ﻋﻤﺎﻥ ﻟﻠﺘﺎﻣﻴﻦ )ﺵ‪.‬ﻡ‪.‬ﻉ(‬
‫‪0102010100891959000006‬‬
‫‪06/09/2024‬‬
‫‪ 53985‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪V‬‬
‫ﺷﺮﻛﺔ ﺍﻻﺧﻮﺓ ﻟﺘﻌﺒﺌﺔ ﻭ ﺗﻮﺯﻳﻊ ﺍﻟﻐﺎﺯﻟﻤﺎﻟﻜﻬﺎﻋﻤﺮ ﻣﺎﺟﺪ ﺍﻟﻐﺮﻳﺮﺷﺮﻛﺔ‬
‫ﺍﻟﺸﺨﺺ ﺍﻟﻮﺍﺣﺪﺫ‪.‬ﻡ‪.‬ﻡ ﻓﺮﻉ ﺩﺑﻲ‬
‫‪ - HINO - 300-‬ﺍﺣﻤﺮ ‪2018 -‬‬
‫‪06/08/2024‬‬
‫ﺑﺴﻴﻄﺔ ‪ -‬ﺍﻟﻤﺆﺧﺮﺓ‬
‫‪The Liable Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫‪ Driver Name‬ﻣﻴﺰﺍﻥ ﺗﺸﺎﺩﻭﺭﻯ ﻣﺎﻧﻴﻚ ﺗﺸﺎﺩﻭﺭﻯ‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪971543191385 Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪01/04/1996 Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫‪ Gender‬ﺫﻛﺮ‬ ‫ﺍﻟﺠﻨﺲ‬
‫‪ Nationality‬ﺑﻨﻐﻼﺩﻳﺶ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪4151175 License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫‪ License Issue Place‬ﺩﺑﻲ‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪29/07/2028 License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫‪9007799562 Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫‪ Insurance Company‬ﺫﻱ‪ .‬ﻧﻴﻮ‪ .‬ﺍﻧﺪﻳﺎ ﺍﺷﻮﺭﻧﺲ ﻛﻮﻣﺒﺎﻧﻲ ﻟﻴﻤﺘﺪ‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫‪904312321363 Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪07/07/2024 Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 65348 Plate Details‬ﺩﺑﻲ ﺧﺼﻮﺻﻲ ‪W‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫‪ Owner Name‬ﻣﻴﺰﺍﻥ ﺗﺸﺎﺩﻭﺭﻯ ﻣﺎﻧﻴﻚ ﺗﺸﺎﺩﻭﺭﻯ‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - -NISSAN - MICRA Make-Model-Color-Year‬ﺍﺑﻴﺾ ‪2020 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ‬
‫‪07/06/2024 Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬
‫‪ Level of Damages‬ﻣﺘﻮﺳﻄﺔ ‪ -‬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