| 1) | Name of the Police Station | Nagothane |
| 2) | CR No./TAR No./SDE No. | 055/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-07-19 Accident Date and Time:- 2021-07-17 23:30:00 Accident Place:- AT. Mumbai-Goa Highway Road Godasai Village Tel. Roha Dist. Raigad Maharashtra |
| 4) | Name of the injured/Deseased | 1. Vikas Maruti Kondalkar 2. Ankit Manohar Kondalkar |
| 5) | Name of the hospital to which he/she was removed | None |
| 6) | Name of vehicle and type of the vehicle | 1. Truck MH 43 BP 2441 2. Bick MH 04 JE 9221 |
| 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. Manoj Shiromani Pathak 2. Ankit Manohar Kondalkar Driver's Address:- 1. AT. Sarshi Khampati Dist. Pratapgad Uttar Pradesh 2. AT. Room No. 87 New Shidarth Nagar Kopari Colony Thane Ewst 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 |
| PN/ 840 S. P. Bhoir Mo. No. 8381027350 | ||
| Inspector of Police | ||
| Nagothane 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 | ||