| 1. |
Police Station Name. |
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GOREGAON POLICE STATION |
| 2. |
CR No. |
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MOTAR ACCIDENT 25/2017 |
| 3. |
Accident No. |
:- |
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| 4. |
Date,Time And Place Of Accident |
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2017-10-21 , 2:30 , AT. AMBET KOND MHASALA TAL SHRIEARDHAN |
| 5. |
Name of Injured/Deceased |
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NAME OF INJURED - MANISH DINESH JADHAV NAME OF DECEASE PERSON - CHETAN PRADIP SAWANT AGE 30 AT. KOKA |
| 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 09 AB 2611 , JEEP |
| 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 |
:- |
CHETAN PRADIP SAWANT AGE 30 AT. KOKARE TAL MAHAD DIST RAIGAD |
| 9. |
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident |
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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. |
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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. |
:- |
Null,0000-00-00 , 0000-00-00 |
| 12. |
Action Taken, If Any, And the Result thereof |
:- |
MAHAD CITY POLICE STATION NO. 25/2017 |
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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. |