[See Rules 253 & 254 (e) (iii) 254 (80 255 (1) (iv)]
1) Name of the Police Station Mhasla
2) CR No./TAR No./SDE No. 003/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-01-30
Accident Date and Time:- 2021-01-30 12:10:00
Accident Place:- At. sai chekpost Tal. Mhasla Dist. Raigad
4) Name of the injured/Deseased 1) Shakuntala Vinayak Aapate 2) Santosh Jabahir Yadav 3) Dyashankar Bharati 4) Javed sinkadar sahab husen 5) nMubarak Pasha
5) Name of the hospital to which he/she was removed
6) Name of vehicle and type of the vehicle 1)Travhals MH.12.KQ.5289 2)Truck KA.16.C4266 3)Car MH.14.J.3917 4)Truck MH.06.AQ.9701
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:- Javed sinkadar sahab husen
Driver's Address:- At. Himatanaga Tal,Dist. Chirtadurg Stat. Karnatak
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
HC/84 S.N. Chavhan
Inspector of Police
Mhasla 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