| 1. |
Police Station Name. |
:- |
KHOPOLI POLICE STATION |
| 2. |
CR No. |
:- |
MOTOR ACCIDENT CR NO 259/2017 |
| 3. |
Accident No. |
:- |
NULL |
| 4. |
Date,Time And Place Of Accident |
:- |
2017-12-14 , 00.34 , AT. NIRAMAY HOSPITAL PANVEL |
| 5. |
Name of Injured/Deceased |
:- |
NAME OF DECEASED - MADHAV GOPAL MALI AGE 61 MUL LODHIWALI WADI TAL KHALPUR DIST RAIGAD |
| 6. |
Name of the Hospital to Which He/She Was Removed |
:- |
Niramay Hospital Plot No 148, Middle Class Society Road, Panvel, Navi Mumbai - 410206 |
| 7. |
Number Of Vehical and type Of the Vehical |
:- |
UNKNOWN , UNKNOWN |
| 8 |
Name and Address Of the Driver Of the
Vehical With Particulars Or Driving License
Of the Said Driver And the Address Of
Issuing Autdority Of the Said Driving
License.the Number Of Badge in Case
Of Public Service Vehical and Address of
Issuing Autdority Of the Said Badge |
:- |
UNKNOWN |
| 9. |
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident |
:- |
UNKNOWN ,UNKNOWN |
| 10. |
Name And Address Of the Insurance Company With Whome the Vehical Was Insured And the Divisional Office Of the Said Insurance Company. |
:- |
Null , Null , Null |
| 11. |
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate. |
:- |
Null,0000-00-00 , 0000-00-00 |
| 12. |
Action Taken, If Any, And the Result thereof |
:- |
KHALAPUR POLICE STATION MOTOR ACCIDENT CR, NO 259/2017 |
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N.B.-tdis from should accompany witd all necessary document viz. (1)F.I.R (2)Panchanama
(3) Medical Certificate/Post-Mortem Report. |
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Inspector of police,
...........Police Station. |