| 1) | Name of the Police Station | Khalapur |
| 2) | CR No./TAR No./SDE No. | 285/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-11-30 Accident Date and Time:- 2021-11-30 21:30:00 Accident Place:- . 29/11/2021 रोजी 21:30 व मौजे मुांबई पुणे एन.एच. 04 ह यवे रोडवर दवणेग व त .ख ल पुर |
| 4) | Name of the injured/Deseased | जयन थ दशवन र यण ज धव , वय 33, धांद च लक, र . ,र . सल्प देवी प ड दडम टगच्य प ठीम गे भ ांडुप मुांबई , मुळ र . आत्मज दशवन र यण दवलेज एकडेगव , पो. सोनह एक्दें ग्ब वस्ती , र ज्य. उत्तरप्रदेश , भ ांडुप , मुांबइ, मह र ष्ट्र, फोन नांबर 9454535272 |
| 5) | Name of the hospital to which he/she was removed | nil |
| 6) | Name of vehicle and type of the vehicle | 1)अशोक लेल न कां पनीच टेम्पो नांबर एम.एच. 03 सी.पी. 1008 2) हुांन्ड ई कां पनी क र नांबर एम.एच. 14 डी.एफ. 367 |
| 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)जयन थ दशवन र यण ज धव , वय 33, धांद च लक, र . ,र . सल्प देवी प ड दडम टगच्य प ठीम गे भ ांडुप मुांबई , मुळ र . आत्मज दशवन र यण दवलेज एकडेगव , पो. सोनह एक्दें ग्ब वस्ती , र ज्य. उत्तरप्रदेश , भ ांडुप , मुांबइ, मह र ष्ट्र, फोन नांबर 9454535272 2)1) हुांन्ड ई 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 | ख ल पूर पोस्टे गुरनां 0285/2021 भ .दां .दव.क. 279 _, मोट र व हन अदधदनयम, 1988 184 प्रम णे |
| पोोे दन श्री. दवभुते स ोो,ख ल पुर पोलीस ठ णे,मो.नां.8805008080 | ||
| 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 | ||