| 1) | Name of the Police Station | Khalapur |
| 2) | CR No./TAR No./SDE No. | 217/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-08-21 Accident Date and Time:- 2021-08-21 15:00:00 Accident Place:- AT. Mumbai-Pune Expressway , Pune Len K. M. 26/600 Near Service Len Tel. Khalapur Dist. Raigad Maharashtra |
| 4) | Name of the injured/Deseased | 1. Antkumar Amrutlal Gupta 2. Sanjayrani Antkumar Gupta 3. Akansha Antkumar Gupta 4. Ronak Antkumar Gupta |
| 5) | Name of the hospital to which he/she was removed | None |
| 6) | Name of vehicle and type of the vehicle | Car MH 04 GU 5742 2. JCB MH 02 EZ 8331 |
| 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:- Antkumar Amrutlal Gupta Driver's Address:- AT. Srushti Owners Court Varad Hospital Near K- Vayti Marg Thane 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/ 743 Kambale Mo. No. 7350055110 | ||
| Inspector of Police | ||
| Khalapur 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 | ||