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.
:-
GOREGAON POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR NO 48/2018
3.
Accident No.
:-
----
4.
Date,Time And Place Of Accident
:-
2018-09-01 , 17:12 , At. Repoli Gaon Area Mumbai To Goa High Way Road Taluka Mangaon District Raigad
5.
Name of Injured/Deceased
:-
Name Of deceased - 1) Dipak Vitthoba Niman At. Kavil Vahal Taluka Mangaon District Raigad Name Of I
6.
Name of the Hospital to Which He/She Was Removed
:-
SUB DIVISIONAL HOSPITAL MANGAON TAL MANGAON DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 06 B L 2876 2) M H 04 G C 7677 , 1) Deo Scooty 2) Truck
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
:-
Saravajit Sahadev Yadav At. Baridiha Post Chakrava ji Devriya Stat. Uttarpradesh Current At. Wapi Rail Station Bharat Bhai chal No 02 Room No 4 Gita Nagar Gujarat
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
Saravajit Sahadev Yadav, At. Baridiha Post Chakrava ji Devriya Stat. Uttarpradesh Current At. Wapi Rail Station Bharat Bhai
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
:-
Goregaon Police Station Motor Accident Cr No 48/2018
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.