1) | Name of the Police Station | Wadkhal |
2) | CR No./TAR No./SDE No. | 086/2021 |
3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-05-21 Accident Date and Time:- 2021-05-21 13:00:00 Accident Place:- AT. Dolavi Village Mumbai- Goa Highway Industrial Hardware Shop At Front Side Mumbai Len Tel. Pen Dist. Raigad Maharashtra |
4) | Name of the injured/Deseased | 1. Sanjay Pandurang Kabari 2. Ronald Yashwant Mosamkar |
5) | Name of the hospital to which he/she was removed | None |
6) | Name of vehicle and type of the vehicle | 1. Bike MH 06 S 8897 2. Trelar MH 46 TS 2860 |
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. Ronald Yashwant Mosamkar 2. Sukrudu Yunus Shekh Driver's Address:- 1. AT. Hamrapur Tel. Pen Dist. Raigad 2. AT. Masjid Bandar Mumbai / AT. Mehandipur Jibanpur Zikra Murshidabad West Bengal 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 | ||
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 |