| 1. |
Police Station Name. |
:- |
MAHAD MIDC POLICE STATION |
| 2. |
CR No. |
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MOTAR ACCIDENT 24/2017 |
| 3. |
Accident No. |
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| 4. |
Date,Time And Place Of Accident |
:- |
2017-10-17 , 19:30 , AT. ASANPOI GAON MIDC FIRE STATION |
| 5. |
Name of Injured/Deceased |
:- |
1) TAIFIK INAYATULLA PATHAN AGE 20 AT. LASAFORM VIRAWADI TAL MAHAD MUL AT. CHIRKUDEWADI TAL VALVA DI |
| 6. |
Name of the Hospital to Which He/She Was Removed |
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RURAL HOSPITAL MAHAD TAL MAHAD DIST RAIGAD |
| 7. |
Number Of Vehical and type Of the Vehical |
:- |
M H 06 B F 2458 , 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 |
:- |
TAIFIK INAYATULLA PATHAN AGE 20 AT. LASAFORM VIRAWADI TAL MAHAD MUL AT. CHIRKUDEWADI TAL VALVA DIST SAGALI |
| 9. |
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident |
:- |
TAIFIK INAYATULLA PATHAN AGE 20 ,AT. LASAFORM VIRAWADI TAL MAHAD MUL AT. CHIRKUDEWADI TAL VALVA DIST SAGALI |
| 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 |
:- |
MAHAD MIDC POLICE STATION MOTOR ACCIDENT 24/2017 |
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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. |