| 1) | Name of the Police Station | Khopoli |
| 2) | CR No./TAR No./SDE No. | 018/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-01-27 Accident Date and Time:- 2021-01-26 02:42:00 Accident Place:- AT. Mumbai-Pune Expressway Food Mall Near Petrol Pump Near Road Pune-Mumbai Len Indian Oil Pump Near Khalapur Dist. Raigad |
| 4) | Name of the injured/Deseased | 1. Nasiruddin Shamshula Khan 2. Shami Mohammad Khan 3. Ajijul Jannam Hasan |
| 5) | Name of the hospital to which he/she was removed | |
| 6) | Name of vehicle and type of the vehicle | 1. Tempo MH 04 HY 7724 2. Unknown Vehicle |
| 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. Nasiruddin Shamshula Khan 2. Unknown vehicle Driver Driver's Address:- 1. AT. Barka Gulriha Hisampur Bhadra Balrampur Dist. Maharajganj Uttar Pradesh 2, Unknown Vehicle 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 |
| PSI Kadam Mo. No. 9762462620 | ||
| Inspector of Police | ||
| Khopoli 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 | ||