1) | Name of the Police Station | Khopoli |
2) | CR No./TAR No./SDE No. | 036/2021 |
3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-02-11 Accident Date and Time:- 2021-02-10 17:30:00 Accident Place:- AT. Pune-Mumbai Express Highway Len K.M. 35/100 Near , Dheku Village, Tal. Khalapur Dis. Raigad |
4) | Name of the injured/Deseased | 1.Pushpendra Singh Virendra Singh Jadom 2. Rajbhadur Yadasv 3. Anis Nadaph |
5) | Name of the hospital to which he/she was removed | None |
6) | Name of vehicle and type of the vehicle | 1. Container KA 25 C 7349 2. Car MH 03 BC 0799 |
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. Container KA 25 C 7349 2. Pushpendra Singh Virendra Singh Jadom Driver's Address:- 1. Container KA 25 C 7349 2. AT. Laxmi Aashirwad Room No. 101 Sector No. 25 Kamothe, Navi Mumbai / AT Ambedkar Nagar MJM College at front side Bhind Madhya Pradesh Licence No:- None Licence's Issuing Authority:- None Badge No:- None Badge's Issuing Authority:- None |
8) | Name and address of the owner of the vehicle as it stands on the date of accident |
Owner Name:- None Owner's Address:- None |
9) | Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance company |
Insurance Company:- None Insurance's Company Address:- None Insurance Company Divisonal Office:- None |
10) | Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate | Insurance Policy No:- None |
11) | Action taken, if any and the result thereof | FIR Report |
PN/ 1386 Dhaygude | ||
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 |