1) | Name of the Police Station | Poyanad |
2) | CR No./TAR No./SDE No. | 009/2021 |
3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-02-14 Accident Date and Time:- 2021-02-14 03:30:00 Accident Place:- AT. Foji Hotel Dharamtar , Alibag Pen Road , Tal. Alibag Dis. Raigad Maharashtra |
4) | Name of the injured/Deseased | 1. Harshal Dilip Bankar 2. Parmesh Prakash Thombre 3. Pranay Tanaji Waghmare 4. Ujjwal Vilas Nimbare |
5) | Name of the hospital to which he/she was removed | None |
6) | Name of vehicle and type of the vehicle | 1. Car MH 02 BR 0942 2. Truck MH 04 FP 5374 |
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. Harshal Dilip Bankar 2. Truck MH 04 FP 5374 Driver's Address:- AT. Bandhan Tal. Alibag Dis. 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 |
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 |
PSI Kale Mo.No. 8379837038 | ||
Inspector of Police | ||
Poyanad 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 |