Accident Detail Receipt
Date And Time 01-Jan-1970 / 8:00 pm
Place of Accident Shirpur Chopada Road Hotal Aakash Gardan Front Side.
CR NO/ TAR No/ SDE NO 40/2017
Name of the Injured/ Deceased Santosh Rajaram Vadar age 52 At.Post varkisaidani Tal.Chopada Dist.Jalgoan
Name of The Hospital to which he/she was removed Navjivan Accidant Hospital Shipur
Number of vehicle and type of the vehicle 1) Cantenar No.H.R.55 5798 2) Motar Cycle No.MH 20 B.P.4703
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) Kabhir Jamil Khan At.Post MajidGhasariya Tal Nuhu Dist.Mewat.( Hariyana State) Driving Licence issue D.T.Officer Wokha Nagaland. Licence No.65956/NW/TV/10 2) Santosh Rajaram Vadar At.Post Warkisaidani Tal.Chopada Dist.Dhule Driving License Issue In RTO Office Jalgoan License No.MH 19 20140018480
Name of the owner of the vehicle as it stand on the date of the accident Delhi Gujarat Freight Corportation Accident Date 15/08/2017 Time 20.00 P.M (No Stand)
Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance Company. 1) H 1A/18 sector 63 Near Domino's Pizza Shop Nodia 201301 Nodia Uttar Pradesh 201301
Number of Insurance Policy/Insurance Certificate and the Date of the validity of the insurance Policy /Insurance Certificate 1) Policy No.272500/31/2017/8903 Issurance Period Date From 00:00 on 31/03/2017 To MidNight Of 30/03/2018
Action Taken if any, and the result thereof. Arrest Date 22/08/2017 In JMFC Court Shirpur

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