[See Rules 253 & 254 (e) (iii) 254 (80 255 (1) (iv)]
1) Name of the Police Station Poladpur
2) CR No./TAR No./SDE No. 021/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-06-05
Accident Date and Time:- 2021-06-06 16:25:00
Accident Place:- AT. Loharmal Village Mumbai-Goa Highway Road Tel Poladpur Dist. Raigad Maharashtra
4) Name of the injured/Deseased Shailesh Kashinath Ajgaonkar
5) Name of the hospital to which he/she was removed None
6) Name of vehicle and type of the vehicle Bick MH 06 CE 3959
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:- Shailesh Kashinath Ajgaonkar
Driver's Address:- AT. Deulkont, Kumbharwadi Tel. Poladpur 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/ 1129 Magar
Inspector of Police
Poladpur 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