| 1) | Name of the Police Station | Nagothane |
| 2) | CR No./TAR No./SDE No. | 060/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-08-15 Accident Date and Time:- 2021-08-14 15:15:00 Accident Place:- AT. Varvathne Village Nagothane MIDC , Varbothane Road Tel. Roha Dist. Raigad Maharashtra |
| 4) | Name of the injured/Deseased | 1. Dattaram Lakshiman Shid 2. Ganesh Kushal Ughada |
| 5) | Name of the hospital to which he/she was removed | None |
| 6) | Name of vehicle and type of the vehicle | Bick MH 06 BQ 5985 2. Truck MH 06 BT 1296 |
| 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. Dattaram Lakshiman Shid 2. Rajaram Sofilal Sahu Driver's Address:- 1. AT. Vasgaon Valechi vadi Po. Nagothane Tel. Roha Dist. Raigad 2. AT. Salav Revdanda Tel. Alibag Dist. Raigad / AT. Pandu Dist. Sidi State Madhyapradesh 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 |
| PN/ 1375 N. V. Patil Mo. No. 9270373856 | ||
| 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 | ||