| 1) | Name of the Police Station | Poladpur |
| 2) | CR No./TAR No./SDE No. | 004/2022 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2022-01-16 Accident Date and Time:- 2022-01-16 14:40:00 Accident Place:- MUMBAI GOA HIGHWAY, 50 METERS FROM OM SAI HOTEL, AT LOHARMAL, TAL- POLADPUR |
| 4) | Name of the injured/Deseased | DEATH-1) SANTOSH KISAN KOLI, 25, AT- SADAVLI AADIVASHIVADI, TAL-POLADPUR |
| 5) | Name of the hospital to which he/she was removed | |
| 6) | Name of vehicle and type of the vehicle | TRELOR RJ19GG8894 |
| 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:- BHOMARAM BHIYA RAM Driver's Address:- AT-47 BHAKARWALI, DHANI BERAD JATI BHANDU, TAL- SHERGAD, JODHPUR, RAJASTAN 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 304(A),279.337,338, MVA 184 |
| HC/772 CHAVAN POLADPUR PS | ||
| Inspector of Police | ||
| Poladpur 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 | ||