1) | Name of the Police Station | Poladpur |
2) | CR No./TAR No./SDE No. | 024/2021 |
3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-06-27 Accident Date and Time:- 2021-06-27 06:15:00 Accident Place:- AT. Kashedi Ghad Dhamndevi Village Mumbai-Goa Highway Road Tel. Poladpur Dist. Raigad Maharashtra |
4) | Name of the injured/Deseased | Dinesh Gopal Dhingankar |
5) | Name of the hospital to which he/she was removed | None |
6) | Name of vehicle and type of the vehicle | 1. Bick MH 08 P 8811 2. Tempo RJ 02 GB 8757 |
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. Dinesh Gopal Dhingankar 2. Manoj Kumar Kartar Singh Driver's Address:- 1. AT. Chindravde Tavdewadi Tel. Guhaghar Dist. Ratnagiri 2. AT. Bus Stand Wheel Tel. Beharul Dist. Alwar RajasthanBus Stand Wheel Tel. Beharul Dist. Alwar Rajasthan 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/ 1101 Pawar Mo. No. 9552657183 | ||
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 |