| 1) | Name of the Police Station | Khalapur |
| 2) | CR No./TAR No./SDE No. | 025/2022 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2022-02-10 Accident Date and Time:- 2022-02-08 23:00:00 Accident Place:- MUMBAI PUNE NH 04 , AT MAHAD PHATA, TAL- KHALAPUR |
| 4) | Name of the injured/Deseased | ENJURED-1) JAYESH RAVINDRA NASHIKKAR, AT- PODI NO.2, SECTOR 16 NEW PANVEL. |
| 5) | Name of the hospital to which he/she was removed | |
| 6) | Name of vehicle and type of the vehicle | TEMPO MH46BM7634, CAR MH05EJ1446 |
| 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:- JAYESH RAVINDRA NASHIKKAR, Driver's Address:- AT- PODI NO.2, SECTOR 16 NEW PANVEL. 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/834 MHATRE KHALAPUR PS | ||
| Inspector of Police | ||
| Khalapur 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 | ||