Export a Table to PDF Template | PrepBootstrap

Accidents Compension Reports

Back Photos

FORM COMPP AA
[see Rules 253,254 (c) (iii),254(80 255(1)(iv)]
REPOR ABOUT THE MOTOR VEHICLES ACCIDENTS

No
Contents
:-
Data
1.
Police Station Name.
:-
POYNAD POLICE STATION
2.
CR No.
:-
52/2018 IPC 279,338 mv act 184
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2018-06-26 , 22:30 , at Chokicha pada Tal Alibag
5.
Name of Injured/Deceased
:-
Injured Person 1) Chandrakant Balaram Patil At Medhekhar Alibag
6.
Name of the Hospital to Which He/She Was Removed
:-
VAIRAGI HOSPITAL PEN TAL PEN DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1 , St Bus & Cycle
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
:-
Hanuman Babasaheb Jagtap At Ramwadi Tal Pen
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
S T Mahamandal,unknown
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
:-
Cr no 52/2018 IPC 279,338 mv act 184 Register at poynad Police station
N.B.-tdis from should accompany witd all necessary document viz. (1)F.I.R (2)Panchanama (3) Medical Certificate/Post-Mortem Report.
Inspector of police, ...........Police Station.