Accident Detail Receipt
Date And Time 17-Nov-2017 / 8:20 am
Place of Accident About 1 K.M.from Shirpur Chopada Road beyond Tardi village
CR NO/ TAR No/ SDE NO 01/2018 IPC 279,337.338,427 MV Act 134/177,184
Name of the Injured/ Deceased Injured Name 1) Santosh Gajanan Lohar 2) Sujata Santosh Lohar A/P Undhirkheda Tal.Parola Dist Jalgaon
Name of The Hospital to which he/she was removed Sahyadari Hospital Nashik
Number of vehicle and type of the vehicle 1) Mahindra Belero MH 19 AX 3260 2) Motar Cycle No.MH 19BV 2539
Name of address of driver of the vehicle with perticuler ordriving license of the said driver and the address of the issuing Authority of the said driver license. The number of badge in case of public service vehicle and the address of the issuing Authority of the said badge. 1) Nana Chintaman Patil A/P Bhokarbari Tal Parola Dist jalgoan Draving Licence No MH 19 20080011009 Issing Authority 2) Santosh Gajanan Lohar A/P Undhirkheda Tal parola Dist Jalgoan Driving Licence No MH 1920140004241
Name of the owner of the vehicle as it stand on the date of the accident 1) Balu Suklal Patil A/P Mangrul Tal Parola Dist Jalgaon 2) Sontosh Gajanan Lohar A-P Undhirkheda Tal.parola Dist Jalgaon
Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance Company. 1) Mahindra Bolero No MH 19 AX 3260 Name Of Insurance Relince Gen.Insurance 106,107,108 1st Floor Space Cosmos Building AshokStmbh Nashik 422002 2) Bajaj Allianz Office C.E Plazza Airport Road Yerwada Pune 411006
Number of Insurance Policy/Insurance Certificate and the Date of the validity of the insurance Policy /Insurance Certificate 1) Mahindra Belero Insurance Police Number 170421723110021439 Insurnace Velidity 22/09/2018 2) Motar Cycle Isurance Police Number DY 1300100517 Velidity Date 01-01-2014
Action Taken if any, and the result thereof. Investigation

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