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.
:-
POLADPUR POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR NO 43/2018
3.
Accident No.
:-
--
4.
Date,Time And Place Of Accident
:-
2018-06-14 , 00:40 , At. Loharmal Gaon Mumbai To Goa Road
5.
Name of Injured/Deceased
:-
Name Of injured - 1) Ganesh Jiwaji Narkar Age 46 2) Puja Ganesh Narkar Age 37 both At. Sidhdarth Na
6.
Name of the Hospital to Which He/She Was Removed
:-
GOVERNMENT HOSPITAL POLADPUR TAL POLADPUR DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
M H 48 K 4741 , luxury bus
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
:-
Vithoba Bapu Malkar Age 27 At. Nandos Gaovthan Taluka Malvan District Sindhudurg
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
Vithoba Bapu Malkar , At. Nandos Gaovthan Taluka Malvan District Sindhudurg
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
:-
POLADPUR POLICE STATION MOTOR ACCIDENT CR NO 43/2018
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.