[See Rules 253 & 254 (e) (iii) 254 (80 255 (1) (iv)]
1) Name of the Police Station Pen
2) CR No./TAR No./SDE No. 199/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-08-31
Accident Date and Time:- 2021-08-31 15:15:00
Accident Place:- AT. Ganpatiwadi Village Ganpati Mandir at front side Khopoli Baypaas Road Tel. Pen Dist. Raigad Maharashtra
4) Name of the injured/Deseased Suresh Govind Kadam
5) Name of the hospital to which he/she was removed None
6) Name of vehicle and type of the vehicle Car MH 06 BE 3242 2. Tankar MH 12 RN 2393
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. Suresh Govind Kadam 2. Unknown
Driver's Address:- 1. AT. Ganpatiwadi Po. Ambeghar Tel. Pen Dist. Raigad 2. Unknown
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
PSI / Patil Mo. No. 8308830380
Inspector of Police
Pen 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