1) | Name of the Police Station | Khalapur |
2) | CR No./TAR No./SDE No. | 009/2021 |
3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-01-07 Accident Date and Time:- 2021-01-07 16:00:00 Accident Place:- AT. Lodhivali Village Place Pune-Mumbai NH 04 highway Road Abhi Beer Shop Samor Tal.Khalapur Dis. Raigad |
4) | Name of the injured/Deseased | Anil Mothichand Choudhril |
5) | Name of the hospital to which he/she was removed | Notfind |
6) | Name of vehicle and type of the vehicle | 1. Truck MH 18 AA 8960 2. Bick MH 06 AD 1397 |
7) | Name and address of the driver of the vehicle with particular or driving licence of the said driver and the address of the issuing authority of the said driving licence. The number of badge in case of public service vehicle and the address of the issuing authority of the said badge |
Driver Name:- 1. Unknown Vehicle Drive 2. Anil Mothichand Choudhril Driver's Address:- 1. Unknown Vehicle Drive 2. Vinayak Kadam Chhaawl Poyanje Ta. Panvel Dis. Raigad Mo.No. 7330875400 Licence No:- Notfind Licence's Issuing Authority:- Notfind Badge No:- Notfind Badge's Issuing Authority:- Notfind |
8) | Name and address of the owner of the vehicle as it stands on the date of accident |
Owner Name:- Notfind Owner's Address:- Notfind |
9) | Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance company |
Insurance Company:- Notfind Insurance's Company Address:- Notfind Insurance Company Divisonal Office:- Notfind |
10) | Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate | Insurance Policy No:- Notfind |
11) | Action taken, if any and the result thereof | FIR Report |
HC/ 1907 Patil | ||
Inspector of Police | ||
Khalapur Police Station | ||
N. B. - This form should accompany with all the necessary document viz. (1) I.R. (2) Panchanama (3) Medical certificate /Post Motern Report |