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.
:-
PEN POLICE STATION
2.
CR No.
:-
---
3.
Accident No.
:-
MOTOR ACCIDENT NO 32/2018
4.
Date,Time And Place Of Accident
:-
2018-09-01 , 21:25 , At. Roda Fata Service Center Somor Taluka Pen
5.
Name of Injured/Deceased
:-
Name Of Injured - Nil
6.
Name of the Hospital to Which He/She Was Removed
:-
NIL
7.
Number Of Vehical and type Of the Vehical
:-
1)M H 06 B M 6740 2) M H 43 Y 4374 , 1) Maruti Eco 2) Gas Trankar
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
:-
Viki Dasharath Patil At. Bhakarwad Post Poynad Taluka Alibag D L No.MH 06 20120009976
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
Viki Dasharath Patil ,At. Bhakarwad Post Poynad Taluka Alibag D L No.MH 06 20120009976
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
:-
PEN POLICE STATION MOTOR ACCIDENT NO 33/2018
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.