| 1) | Name of the Police Station | Khalapur |
| 2) | CR No./TAR No./SDE No. | 003/2021 |
| 3) | Date, Time and place of the accident |
Case Reg. Date :- 2021-01-02 Accident Date and Time:- 2021-01-02 10:25:00 Accident Place:- Khalapur Toll Naka Ta. Khalapur Dis. Raigad Maharashtra |
| 4) | Name of the injured/Deseased | Omkar Milind Banthagle |
| 5) | Name of the hospital to which he/she was removed | Notfind |
| 6) | Name of vehicle and type of the vehicle | 1. Car MH 04 DJ 6748 2. Car MH 05 EA 4520 |
| 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. Omkar Milind Banthagle 2. Mahammed Iqbal Sayyed Driver's Address:- 1. AT Bangla No.2 Amruthmanthan Society Shastri Nagar Devi Chowk RBI Colony West 421202 Khalapur Raigad 2. AT. Mumbai Cheta Camp C Sector 1 Line No. 34 Trombay Mumbai Licence No:- Notfind Licence's Issuing Authority:- Notfind 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 | Accident Reporrt |
| HC/ 743 Kadam | ||
| Inspector of Police | ||
| Khalapur 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 | ||