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

‫‪Affected Party Copy‬‬ ‫‪13931‬‬ ‫‪223010350869‬‬

‫ﻣﺮﻛﺰ ﺷﺮﻃﺔ ﺍﻟﺒﺮﺷﺎﺀ‬ ‫ﺍﻟﻤﺮﻛﺰ‬ ‫‪24/06/2023‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ ‪Report Date /‬‬

‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ‬

‫‪2‬‬ ‫ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ‬ ‫ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ‬ ‫‪24/06/2023‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ‬
‫‪No. of Vehicles Involved‬‬ ‫‪Primary Cause‬‬ ‫‪Accident Date‬‬

‫ﻣﻌﺒﺪ ‪ -‬ﺟﺎﻑ‬ ‫ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ‬ ‫ﻻ ﻳﻮﺟﺪ‬ ‫ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ‬ ‫‪15:01‬‬ ‫ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ‬
‫‪Road Condition‬‬ ‫‪Secondary Cause‬‬ ‫‪Accident Time‬‬

‫ﻟﻴﻼً ‪ -‬ﺍﻹﺿﺎﺀﺓ‬ ‫ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ‬ ‫ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ‬ ‫ﺍﻟﻤﻮﻗﻊ‬

‫ﺻﺪﻡ ‪ -‬ﻣﺮﻛﺒﺔ‬ ‫ﻣﻨﻄﻘﺔ ﺍﻟﺒﺮﺷﺎﺀ‬
‫ﻛﺎﻓﻴﺔ‬ ‫‪Visibility‬‬ ‫‪Type of Accident‬‬ ‫‪Location‬‬

‫‪The Affected Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﻀﺮﺭ )( ‪/‬‬ ‫‪The Liable Party‬‬ ‫ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ ‪/‬‬
‫ﻣﺤﻤﺪ ﻣﻌﺎﺫ ﻣﺤﻤﺪ ﺍﻟﺨﻄﻴﺐ‬ ‫‪ Driver Name‬ﺭﺍﺟﻮ ﺑﺎﻧﻴﺮﺳﻴﻠﻔﺎﻡ ﺑﺎﻧﻴﺮ ﺳﻴﻠﻔﺎﻡ‬ ‫ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ‬
‫‪507453884‬‬ ‫‪509869054 Mobile Number‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫‪12/12/1985‬‬ ‫‪Age‬‬ ‫ﺍﻟﻌﻤﺮ‬
‫ﺫﻛﺮ‬ ‫‪0 Gender‬‬ ‫ﺍﻟﺠﻨﺲ‬
‫ﺍﻻﺭﺩﻥ‬ ‫‪ Nationality‬ﺍﻟﻬﻨﺪ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪4466607‬‬ ‫‪1097902 License No‬‬ ‫ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ‬
‫ﺩﺑﻲ‬ ‫‪ License Issue Place‬ﺃﺑﻮﻇﺒﻲ‬ ‫ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ‬
‫‪05/04/2028‬‬ ‫‪07/07/2025 License Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ‬
‫‪-‬‬ ‫‪9007373873 Liable Party Fine No‬‬ ‫ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ‬
‫‪ - Abu Dhabi National Insurance Company Insurance Company‬ﺷﺮﻛﻪ‬
‫‪ - Al Buhaira Insurance Company‬ﺷﺮﻛﻪ ﺍﻟﺒﺤﻴﺮﻩ ﻟﻠﺘﺎﻣﻴﻦ‬ ‫ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ‬
‫ﺍﺑﻮﻇﺒﻰ ﺍﻟﻮﻃﻨﻴﻪ ﻟﻠﺘﺎﻣﻴﻦ‬
‫‪DB022105‬‬ ‫‪HOT2214767 Policy No‬‬ ‫ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪24/09/2023‬‬ ‫‪31/07/2023 Ins. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ‬
‫‪ 91399‬ﺍﻟﺸﺎﺭﻗﺔ ﺧﺼﻮﺻﻲ ‪3‬‬ ‫‪ 35502 Plate Details‬ﺃﺑﻮﻇﺒﻲ ﺧﺼﻮﺻﻲ ‪10‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ‬
‫ﺍﻟﺼﻘﺮ ﻟﺘﺎﺟﻴﺮ ﺍﻟﺤﺎﻓﻼﺕ ﻭﺍﻟﺴﻴﺎﺭﺍﺕ‬ ‫‪ Owner Name‬ﺭﺍﺟﻮ ﺑﺎﻧﻴﺮﺳﻴﻠﻔﺎﻡ ﺑﺎﻧﻴﺮ ﺳﻴﻠﻔﺎﻡ‬ ‫ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪ - TOYOTA/HILUX - - WHITE‬ﺍﺑﻴﺾ ‪2021 -‬‬ ‫‪ - HONDA/ACCORD - - BEIGE Make-Model-Color-Year‬ﺑﻴﺞ ‪2010 -‬‬ ‫ﺍﻟﻨﻮﻉ‪-‬ﺍﻟﻄﺮﺍﺯ‪-‬ﺍﻟﻠﻮﻥ‪-‬ﺍﻟﺴﻨﺔ‬
‫‪24/08/2023‬‬ ‫‪30/06/2023 Reg. Expiry Date‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ‬
‫ﺑﺴﻴﻄﺔ ‪ -‬ﻓﻲ ﺍﻟﻤﻮﺧﺮﺓ‬ ‫‪ Level of Damages‬ﺑﺴﻴﻄﺔ ‪ -‬ﺍﺿﺮﺍﺭ ﺑﺴﻴﻄﺔ ﻓﻲ ﺍﻟﻤﻘﺪﻣﻪ‬ ‫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