| 1) | Name of the Police Station | Wadkhal |
| 2) | CR No./TAR No./SDE No. | 041/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-04-02 Accident Date and Time:- 2021-03-02 00:45:00 Accident Place:- AT. Devli Village Shalimar Hotel Parking Mumbai-Goa Highway Road Near Tal. Pen Dist. Raigad Maharashtra |
| 4) | Name of the injured/Deseased | Vanita Sandip Navale |
| 5) | Name of the hospital to which he/she was removed | None |
| 6) | Name of vehicle and type of the vehicle | 1. Truck MH 46 AR 0713 2.Eco Car MH 02 DZ 1542 |
| 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. Sharfuddin Ali Mohammed Darji 2. Jignesh Ramchandra Ahire Driver's Address:- 1.AT. Kalamboli Bima Complex 2. AT. Ramgarh Nagar Sai Sadhan Chawl Ashwarya Tower Mumbai 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/ 864 Dhupakar Mo.No. 9552927864 | ||
| Inspector of Police | ||
| Wadkhal 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 | ||