| 1) | Name of the Police Station | Kolad |
| 2) | CR No./TAR No./SDE No. | 019/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-03-30 Accident Date and Time:- 2021-03-30 08:45:00 Accident Place:- AT. Kham Village P.U.C. Center frond side Tal. Roha Dist Raigad |
| 4) | Name of the injured/Deseased | Akash Atmaram Raut |
| 5) | Name of the hospital to which he/she was removed | None |
| 6) | Name of vehicle and type of the vehicle | 1. Bike MH 02 EB 6041 2. Traila MH 46 BB 5964 |
| 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. Chetan Chandrakant Mankar 2. Mufid Mohammad Hanif Khan Driver's Address:- 1. Kalaboli Tal. Panvel Dist. Raigad 2. AT. Room No. 66 Sainagar ,Marol, Paipeline Andheri West Mumbai Kalsabde , Muthavli Tal Tala 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 |
| HC/R.R, Raul Mo.No. 8793741982 | ||
| Inspector of Police | ||
| Kolad 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 | ||