| 1) | Name of the Police Station | Mangaon |
| 2) | CR No./TAR No./SDE No. | 069/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-03-27 Accident Date and Time:- 2021-03-27 21:00:00 Accident Place:- AT. Hodgaon Village Hodgaon to Mangaon Road Tal. Mangaon Dist. Raigad Maharashtra |
| 4) | Name of the injured/Deseased | 1. Rajesh Rama Hilam 2. Nathuram Maruti Hilam 3. Jayram Suresh Jadhav |
| 5) | Name of the hospital to which he/she was removed | None |
| 6) | Name of vehicle and type of the vehicle | 1. Pickup Tempo MH 06 AG 5202 2. Bick MH 06 AJ 942 |
| 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. Sachin Parshuram Dalvi 2. Rajesh Rama Hilam Driver's Address:- 1. AT. Wardoli Tal. Mahad Dist. Raigad 2. AT. Hodgaon Adiwasiwadi Tal. Mangaon Dist. Raigad Licence No:- None Licence's Issuing Authority:- None Badge No:- None Badge's Issuing Authority:- None |
| 8) | Name and address of the owner of the vehicle as it stands on the date of accident |
Owner Name:- None Owner's Address:- None |
| 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:- None Insurance's Company Address:- None Insurance Company Divisonal Office:- None |
| 10) | Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate | Insurance Policy No:- None |
| 11) | Action taken, if any and the result thereof | FIR Report |
| ASI/ Wadve Mo. No. 9673128567 | ||
| Inspector of Police | ||
| Mangaon 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 | ||