[See Rules 253 & 254 (e) (iii) 254 (80 255 (1) (iv)]
1) Name of the Police Station Roha
2) CR No./TAR No./SDE No. 011/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-01-24
Accident Date and Time:- 2021-01-23 08:30:00
Accident Place:- At tambdi tal roha dist raigad
4) Name of the injured/Deseased 1) ramesh kashinath bhagat 2) sandanand ramchindra pashilakar
5) Name of the hospital to which he/she was removed
6) Name of vehicle and type of the vehicle 1) MH 06 Y 5893
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:- anone
Driver's Address:- anone Address
Licence No:- not find
8) Name and address of the owner of the vehicle as it stands on the date of accident Owner Name:- not find
9) Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance company
10) Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate
11) Action taken, if any and the result thereof fir report
H C 2041 S S adhikari
Inspector of Police
Roha 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