| 1. |
Police Station Name. |
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KHOPOLI POLICE STATION |
| 2. |
CR No. |
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MOTAR ACCIDENT 135/2017 |
| 3. |
Accident No. |
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| 4. |
Date,Time And Place Of Accident |
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2017-10-22 , 12:5 , AT. DASTURI GAON MUMBAI GOA HIGH WAY ROAD |
| 5. |
Name of Injured/Deceased |
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NAME OF INJURED - PRAVIN POPAT ROMAN AT.DARDAJI TAL KHATAV DIST SATARA |
| 6. |
Name of the Hospital to Which He/She Was Removed |
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PARMAR HOSPITAL LONAVALA TAL MAVAL DIST PUNE |
| 7. |
Number Of Vehical and type Of the Vehical |
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1) M H 12 K N 8866 2) M H 46 A F 9108 , 1) TRAILER 2) HONDA XCENT CAR |
| 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 |
:- |
PRAVIN POPAT ROMAN AT.DARDAJI TAL KHATAV DIST SATARA LIN- 11-20080011233 |
| 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. |
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Null,0000-00-00 , 0000-00-00 |
| 12. |
Action Taken, If Any, And the Result thereof |
:- |
KHALAPUR POLICE STATION MOTOR ACCIDENT NO 135/2017 |
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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. |