[See Rules 253 & 254 (e) (iii) 254 (80 255 (1) (iv)]
1) Name of the Police Station Alibag
2) CR No./TAR No./SDE No. 014/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-02-16
Accident Date and Time:- 2021-01-17 22:15:00
Accident Place:- AT. Vaishet Thal Athavada Bajar near Alibag-Revas Road , Tal. Alibag Dis. Raigad Maharashtra
4) Name of the injured/Deseased Smita Nandakishor Sathe
5) Name of the hospital to which he/she was removed None
6) Name of vehicle and type of the vehicle 1. Bike MH 06 BR 9629 2. Bike MH 46 Y 9231
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:- Jeetendra Kailas Sharma
Driver's Address:- AT. Veshi 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
PN/ 1223 R.K Pingle Mo.No. 7249303030
Inspector of Police
Alibag 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