| 1. |
Police Station Name. |
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KHOPOLI POLICE STATION |
| 2. |
CR No. |
:- |
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| 3. |
Accident No. |
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MOTOR ACCIDENT NO 140/2017 |
| 4. |
Date,Time And Place Of Accident |
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2017-11-05 , 16:15 , AT. DEKU GAON MUMBAI PUNE OLD HIGH WAY KM 36 |
| 5. |
Name of Injured/Deceased |
:- |
NIL |
| 6. |
Name of the Hospital to Which He/She Was Removed |
:- |
NIL |
| 7. |
Number Of Vehical and type Of the Vehical |
:- |
M H 48 AJ 6743 , TEMPO |
| 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 |
:- |
ANIL PANDURANG SURYAWANSHI AGE 32 LIC.MH 02 20090151671 AT. HANUMAN TEKADI CHAL L M ROAD DAHISAR WEST MUMBAI 68 |
| 9. |
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident |
:- |
ANIL PANDURANG SURYAWANSHI,AT. HANUMAN TEKADI CHAL L M ROAD DAHISAR WEST MUMBAI 68 |
| 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 |
:- |
KHOPOLI POLICE STATION MOTOR ACCIDENT NO 140/2017 |
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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. |