| 1) | Name of the Police Station | Goregaon |
| 2) | CR No./TAR No./SDE No. | 002/2022 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2022-01-03 Accident Date and Time:- 2022-01-03 17:00:00 Accident Place:- MUMBAI GOA HIGHWAY AT LONERE PHATA NEAR USARGHAR GAON IN FRONT OF GEL GAS PINE LINE OFFICE, GOREGAON, TAL-MANGAON |
| 4) | Name of the injured/Deseased | ENJURED- 1) KOMAL PRAVIN JAMDADE AT- BUILDING NIO 7/302 MOHAN HIGHLANDS KATRAJ, BADALAPUR EAST THANE. 2) UNKHOWEN, 3) UNKNOWN |
| 5) | Name of the hospital to which he/she was removed | |
| 6) | Name of vehicle and type of the vehicle | CAR MH05EA1204, CAR MH06CD 2538 |
| 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:- SANTOSH BALVANT PANVALKAR Driver's Address:- AT- KAKARTALE MAHAD, TAL-MAHAD Licence No:- NIL |
| 8) | Name and address of the owner of the vehicle as it stands on the date of accident | Owner Name:- NIL |
| 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 | CRIME REGISTER IPC 279.337 MVA 184 |
| HC/2120 B.S.DABHADE GOREGAON PS | ||
| Inspector of Police | ||
| Goregaon 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 | ||