1) | Name of the Police Station | Kolad |
2) | CR No./TAR No./SDE No. | 100/2021 |
3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-11-29 Accident Date and Time:- 2021-11-29 09:00:00 Accident Place:- वामौजेखांबगावचेहददीतसुकेळीखिंडीतमुंबइ्रवामौजेखांबगावचेहददीतसुकेळीखिंडीतमुंबइ्रगोवारोडवर, ता.रोहा , जि.रायगड , महाराष्टगोवारोडवर, ता.रोहा , जि.रायगड , महाराष्ट |
4) | Name of the injured/Deseased | विशालरघुनाथशेते , वय 36, धंदानोकरी , रा. रा.महामार्गपोलीसमदतकेंद्रवाकण , ता.रोहा , रायगड , महाराष्ट , फोननंबर 9158217193 |
5) | Name of the hospital to which he/she was removed | none |
6) | Name of vehicle and type of the vehicle | 1)कंटेनरक्र. एच.आर.55/वाय/6136 2) |
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) सुनिलसिंगसंतोषरजपुत , वय 33, रा. रा.गल्लीनं.2, 30 फुटारोड, अनुवरातविहार, चैहानपटटी,करवालनगर, दिल्लीपिन 110094 Driver's Address:- 1) सुनिलसिंगसंतोषरजपुत , वय 33, रा. रा.गल्लीनं.2, 30 फुटारोड, अनुवरातविहार, चैहानपटटी,करवालनगर, दिल्लीपिन 110094 Licence No:- NIL Licence's Issuing Authority:- NIL Badge No:- nil Badge's Issuing Authority:- nil |
8) | Name and address of the owner of the vehicle as it stands on the date of accident |
Owner Name:- NIL Owner's Address:- NIL |
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:- nil Insurance's Company Address:- NIL Insurance Company Divisonal Office:- nil |
10) | Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate | Insurance Policy No:- nil |
11) | Action taken, if any and the result thereof | कोलाडपोस्टेगुरनं 0100/2021 भा.दं.वि.क. 279 , 337, मोटारवाहनअधिनियम, 1988 184 प्रमाणे |
पोसईश्री.ए.एल.घायवटकोलाडपोलीसठाणेमो.नं.9145585274 | ||
Inspector of Police | ||
Kolad 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 |