| 1) | Name of the Police Station | Khopoli |
| 2) | CR No./TAR No./SDE No. | 165/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-05-06 Accident Date and Time:- 2021-05-06 07:15:00 Accident Place:- Patel nagar Shilphata Khopoli Old Pune Mumbai Expressway Khalapur Raigad Maharashtra |
| 4) | Name of the injured/Deseased | 1) Khajapa Dharma Juber 2) Alauddin Jahangir |
| 5) | Name of the hospital to which he/she was removed | Notfind |
| 6) | Name of vehicle and type of the vehicle | KN 22 CN 0996 |
| 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:- Khajapa Dharma Juber Driver's Address:- AT. Pathsavli Po. Aaland Ta., Di. Gulbarga Karnataka Licence No:- Notfind Licence's Issuing Authority:- NoNotfind Badge No:- Notfind Badge's Issuing Authority:- Notfind |
| 8) | Name and address of the owner of the vehicle as it stands on the date of accident |
Owner Name:- Notfind Owner's Address:- Notfind |
| 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:- Notfind Insurance's Company Address:- Notfind Insurance Company Divisonal Office:- Notfind |
| 10) | Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate | Insurance Policy No:- Notfind |
| 11) | Action taken, if any and the result thereof | Notfind |
| API Kadam | ||
| 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 | ||