[See Rules 253 & 254 (e) (iii) 254 (80 255 (1) (iv)]
1) Name of the Police Station Mandwa Coastal
2) CR No./TAR No./SDE No. 002/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-02-05
Accident Date and Time:- 2021-02-04 18:00:00
Accident Place:- At. Zirad, More Narsari at Front, Alibag Revas Rod Tal. Alibag Dist. Raigad
4) Name of the injured/Deseased 1) Mayat Name Jayendr Govind Patil
5) Name of the hospital to which he/she was removed none
6) Name of vehicle and type of the vehicle 1) Tempo MH.06.BW.0758 2) Two vhilara MH.06.AJ.3966
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) Amit Hirachand Jain
Driver's Address:- At. Shriram Tal. Alibag Dist. Raigad
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
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/1003 A.D.Solase
Inspector of Police
Mandwa Coastal 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