| 1) | Name of the Police Station | Roha |
| 2) | CR No./TAR No./SDE No. | 086/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-07-20 Accident Date and Time:- 2021-07-19 11:50:00 Accident Place:- AT. Roha Kolad Raykar Park Near Vaibhav Jewellers at front side Roha Tel. Roha Dist. Raigad Maharashtra |
| 4) | Name of the injured/Deseased | Sandip Morling Jangam |
| 5) | Name of the hospital to which he/she was removed | None |
| 6) | Name of vehicle and type of the vehicle | 1. Bick MH 06 BK 4883 |
| 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:- Sandip Morling Jangam Driver's Address:- AT. Bhuvaneshwar Tel. Roha Dist. Raigad Licence No:- None |
| 8) | Name and address of the owner of the vehicle as it stands on the date of accident | Owner Name:- None |
| 9) | Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance company | |
| 10) | Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate | |
| 11) | Action taken, if any and the result thereof | FIR Report |
| HC/ 2041 S. S. Adhikari Mo. No. 9421170759 | ||
| Inspector of Police | ||
| Roha 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 | ||