| 1) | Name of the Police Station | Khopoli |
| 2) | CR No./TAR No./SDE No. | 009/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-01-12 Accident Date and Time:- 2021-01-11 01:00:00 Accident Place:- AT. Pune-Mumbai Expressway Dheku Village Place KM. 63/700 Near Khalapur Raigad Maharashtra |
| 4) | Name of the injured/Deseased | 1. Nasim Ahmad Khan 2. Kalimun Nisa Nasir Khan |
| 5) | Name of the hospital to which he/she was removed | Not Fint |
| 6) | Name of vehicle and type of the vehicle | 1. Car MH 04 JV 8200 2. Tempo KA 02 FE 3710 |
| 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. Mahammadyusuf Ebrar Khan 2. Sheikh Sharif Hussain Sahab Driver's Address:- 1. AT. 'B' 208 Shadi Mahal Hall Near Amrutnagar Mumbra Thane Maharashtra . 2. AT. Halgiri Road Government Hospital Outside C/O Chadu Kambli Tal. Ranebennur Dis. Haveri Karnataka Licence No:- Not Fint Licence's Issuing Authority:- Not Fint Badge No:- Not Fint Badge's Issuing Authority:- Not Fint |
| 8) | Name and address of the owner of the vehicle as it stands on the date of accident |
Owner Name:- Not Fint Owner's Address:- Not Fint |
| 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:- Not Fint Insurance's Company Address:- Not Fint Insurance Company Divisonal Office:- Not Fint |
| 10) | Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate | Insurance Policy No:- Not Fint |
| 11) | Action taken, if any and the result thereof | FIR Report |
| HC/ 2067 Patil | ||
| Inspector of Police | ||
| Khopoli 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 | ||