| 1. |
Police Station Name. |
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GOREGAON POLICE STATION |
| 2. |
CR No. |
:- |
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| 3. |
Accident No. |
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MOTOR ACCIDENT NO 26/2017 |
| 4. |
Date,Time And Place Of Accident |
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2017-11-06 , 14:30 , AT. KHANPALE GAON RELASNCE PETROL PUMP MUMBAI GOA HIGH WAY ROAD |
| 5. |
Name of Injured/Deceased |
:- |
YASHAVAN DHONDU RAUT AGE 45 AT. VADPALE TAL MANGAON 2) VISHAL RAJENDRA KADAM AGE 18 AT. LAKHAPALE TA |
| 6. |
Name of the Hospital to Which He/She Was Removed |
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SUB DIVISIONAL HOSPITAL MANGOAN |
| 7. |
Number Of Vehical and type Of the Vehical |
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11) dz- MH/06-Z 4031 2) MH/04-FU/9863 , 1) RIKSHA 2) TRUCK |
| 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 |
:- |
MARUTI VITU SHIGAVAN AGE 52 AT KHANDAPLE TAL MANGAON |
| 9. |
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident |
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MARUTI VITU SHIGAVAN , AT KHANDAPLE TAL MANGAON |
| 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 |
:- |
GOREGAON POLICE STATION MOTOR ACCIDENT NO 26/2017 |
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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. |