ﺷﻬــﺎﺩﺓ ﺗﺄﻣﻴــــﻦ
ﺍﻟﺮﻗﻢ ﺍﻟﺘﻌﺮﻳﻔﻲ ID NO : A-BURJ-1-B-16-002 :
Seq. No Regn No Manufacture Model Vehicle Year Chassis Number Repair Type
ﺍﻟﺮﻗﻢ ﺍﻟﺘﺴﻠﺴﻠﻲ ﺭﻗﻢ ﺍﻟﻠﻮﺣﺔ ﺻﺎﻧﻊ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﻮﺩﻳﻞ ﺳﻨﺔ ﺍﻟﺼﻨﻊ ﺭﻗﻢ ﺍﻟﻬﻴﻜﻞ ﻧﻮﻉ ﺍﻻﺻﻼﺡ
719040120 ﺏ ﻁ ﻥ 9080 Toyota 2ﺑﻜﺐ ﻏﻤﺎﺭﺗﻴﻦ 2024 MR0BB8CDXR6500498 N/A
ﺑﻬﺬﺍ ﺗﺸﻬﺪ ﺷﺮﻛﺔ ﺑﺮﻭﺝ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ ﺑﺄﻥ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﺪﻭﻧﺔ ﺃﻋﻼﻩ ،ﻣﺆﻣﻨﺔ ﻟﺪﻳﻬﺎ ﺑﻤﻮﺟﺐ ﺷﺮﻭﻁ ﺍﻟﻮﺛﻴﻘﺔ ﺃﺩﻧﺎﻩ
01/20/2024/001047 : ﺭﻗﻢ ﻭﺛﻴﻘﺔ ﺍﻟﺘﺄﻣﻴﻦ
:ﺷﺮﻛﺔ ﻗﻮﺍﻓﻞ ﺍﻟﻤﺘﺤﺪﺓ ﻟﻠﻤﻘﺎﻭﻻﺕ )ﺷﺮﻛﺔ ﺍﻟﺸﺨﺺ ﺍﻟﻮﺍﺣﺪ ﺫﺍﺕ ﻣﺴﺌﻮﻟﻴﺔ ﻣﺤﺪﻭﺩﺓ( ﺍﺳﻢ ﺍﻟﻤﺆﻣﻦ ﻟﻪ
:ﻣﺠﻤﻮﻋﺎﺕ ﺿﺪ ﺍﻟﻐﻴﺮ ﻧﻮﻉ ﺍﻟﺘﺄﻣﻴﻦ
2025/09/24 : ﻧﻬﺎﻳﺔ ﺍﻟﺘﺄﻣﻴﻦ 2024/10/14 : ﺑﺪﺍﻳﺔ ﺍﻟﺘﺄﻣﻴﻦ
ﺗﻌﺘﺒﺮ ﻫﺬﻩ ﺍﻟﺸﻬﺎﺩﺓ ﺍﻟﺼﺎﺩﺭﺓ ﺑﻤﻮﺟﺐ ﻭﺛﻴﻘﺔ ﺍﻟﺘﺄﻣﻴﻦ ﺃﻋﻼﻩ ﺑﻤﺜﺎﺑﺔ ﻛﻔﺎﻟﺔ ﻏﺮﻡ ﻭﺃﺩﺍﺀ ﻟﻠﺤﻖ ﺍﻟﺨﺎﺹ ﺑﺎﻟﻨﺴﺒﺔ ﻟﻠﻄﺮﻑ ﺍﻟﺜﺎﻟﺚ )ﺑﻤﺎ ﻓﻲ ﺫﻟﻚ ﺍﻟﻤﻤﺘﻠﻜﺎﺕ ﺃﻭ
ﺍﻹﺻﺎﺑﺎﺕ ﺍﻟﺠﺴﺪﻳﺔ ﺃﻭ ﺍﻷﺭﻭﺵ ﻭﺍﻟﺪﻳﺎﺕ( ﻭﺫﻟﻚ ﻋﻦ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ ﺍﻟﻤﺪﻧﻴﺔ ﺍﻟﻨﺎﺟﻤﺔ ﻋﻦ ﻭﻗﻮﻉ ﺣﺎﺩﺙ ﺗﻜﻮﻥ ﺍﻟﻤﺮﻛﺒﺔ ﺍﻟﻤﺆﻣﻨﺔ ﻃﺮﻓﺎ ﻓﻴﻪ ﻭﺫﻟﻚ ﻓﻲ ﺣﺪﻭﺩ
ﻧﺴﺒﺔ ﺍﻟﺨﻄﺄ ﺍﻟﺘﻲ ﺗﺤﺪﺩﻫﺎ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺮﺳﻤﻴﺔ ﺍﻟﻤﺨﺘﺼﺔ ﻋﻠﻰ ﺳﺎﺋﻘﻬﺎ ﺷﺮﻳﻄﺔ ﺗﻄﺒﻴﻖ ﺷﺮﻭﻁ ﻭﺃﺣﻜﺎﻡ ﻭﺍﺳﺘﺜﻨﺎﺀﺍﺕ ﻭﺛﻴﻘﺔ ﺍﻟﺘﺄﻣﻴﻦ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺃﻋﻼﻩ.
Names of authorized drivers under the age of 18 ﺍﻟﺴﺎﺋﻘﻴﻦ ﺍﻟﻤﺴﻤﻴﻴﻦ ﺍﻹﺿﺎﻓﻴﻴﻦ ﺍﻟﺬﻳﻦ ﺗﻘﻞ ﺃﻋﻤﺎﺭﻫﻢ ﻋﻦ 18ﺳﻨﺔ
)(with driving licenses numbers )ﻣﻊ ﺭﻗﻢ ﺭﺧﺺ ﺍﻟﻘﻴﺎﺩﺓ ﺍﻟﺨﺎﺻﺔ ﺑﻬﻢ(
ﺍﻟﻌﻼﻗﺔ ﺑﺎﻟﻤﺆﻣﻦ ﻟﻪ ﺍﻟﺠﻨﺲ ﺍﻟﻬﺎﺗﻒ ﺍﻟﻌﻨﻮﺍﻥ )ﺍﻟﻤﺪﻳﻨﺔ( ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ ﺍﻟﻌﻤﺮ ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ
Relationship with Gender Phone No. Address City Date of Birth Age ID Number Name of Driver
Insured
920000560 ﻓﻲ ﺣﺎﻝ ﻭﻗﻮﻉ ﺣﺎﺩﺙ ﻣﺮﻭﺭﻱ ﺍﻹﺗﺼﺎﻝ ﺏ ﻧﺠﻢ ﻋﻠﻰ ﺍﻟﺮﻗﻢ
ﻣﻊ ﺍﻹﻟﺘﺰﺍﻡ ﺑﺘﻘﺪﻳﻢ ﺟﻤﻴﻊ ﺍﻟﺒﻴﺎﻧﺎﺕ ﻭﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺗﻘﺪﻳﻢ ﺍﻟﺒﻼﻍ ﻫﺎﺗﻔﻴﺎ ﻭﻟﻤﺤﻘﻖ ﺍﻟﺤﻮﺍﺩﺙ
ﺷﺮﻛﺔ ﺑﺮﻭﺝ ﻟﻠﺘﺄﻣﻴﻦ ﺍﻟﺘﻌﺎﻭﻧﻲ
