| 1. |
Police Station Name. |
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PALI POLICE STATION |
| 2. |
CR No. |
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| 3. |
Accident No. |
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MOTOR ACCIDENT NO 14/2007 |
| 4. |
Date,Time And Place Of Accident |
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2017-12-29 , 23:30 , AT. DHATAHV TO ROHA RAOD S T STAND |
| 5. |
Name of Injured/Deceased |
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NAME OF INJURED - 1) VINOD DATTARAM MATE AGE 31 AT. BHISE TAL ROHA 2) YOGESH BHASKAR MORE AGE 32 AT. |
| 6. |
Name of the Hospital to Which He/She Was Removed |
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SUB DIVISIONAL HOSPITAL ROHA TALUKA ROHA DIST RAIGAD |
| 7. |
Number Of Vehical and type Of the Vehical |
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M H 06 AX 7952 , MOTOR CYCLE |
| 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 |
:- |
1) VINOD DATTARAM MATE AGE 31 AT. BHISE TAL ROHA |
| 9. |
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident |
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VINOD DATTARAM MATE ,AT. BHISE TAL ROHA |
| 10. |
Name And Address Of the Insurance Company With Whome the Vehical Was Insured And the Divisional Office Of the Said Insurance Company. |
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Null , Null , Null |
| 11. |
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate. |
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Null,0000-00-00 , 0000-00-00 |
| 12. |
Action Taken, If Any, And the Result thereof |
:- |
ROHA POLICE STATION MOTOR ACCIDENT NO 14/2017 |
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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. |