Accident Detail Receipt
Date And Time 04-Jan-2017 / 10:00 am
Place of Accident Wadi to Vaghdi Road / Rameshwar Natu Gosavi his formsi face by Road Shirpur tal shirpur dist.Dhule (ms)
CR NO/ TAR No/ SDE NO shirpur ps cr no- 114/2017 IPC-304 A,279,338,427 MV Act.184/177
Name of the Injured/ Deceased Darasing Valsing pavra age -32 Add-Javai Nagar Ward no-13 Pansemal Tal Pansemal dist.Badvani (M P) (DEATH)
Name of The Hospital to which he/she was removed Cottage Hospital Shirpur Dist. dhule
Number of vehicle and type of the vehicle Kali pili MH-19/Y 326V
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. Shantaram Bajirao Bhil Add Boradi tal-shirpur Dist.Dhule (MS) RTO- D L NO- Valid-
Name of the owner of the vehicle as it stand on the date of the accident -
Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance Company. -
Number of Insurance Policy/Insurance Certificate and the Date of the validity of the insurance Policy /Insurance Certificate -
Action Taken if any, and the result thereof. -

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