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Accidents Compension Reports

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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.
:-
MAHAD MIDC POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 27/2017
4.
Date,Time And Place Of Accident
:-
2017-11-22 , 12:30 , AT. MOZERI GOAN WAGJAI MANDIR TURN MAHAD BHOR ROAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - SACHIN SITARAM TIKHE AGE 34 AT. JANTA VASAHAT PARVATI PUEN TAL PUNE DIST PUNE 2) R
6.
Name of the Hospital to Which He/She Was Removed
:-
RURAL HOSPITAL MAHAD TAL MAHAD DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 12 FS 5891 2) M H 12 LL 9588 , MOTOR 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
:-
1) SACHIN SITARAM TIKHE AGE 34 AT. JANTA VASAHAT PARVATI PUNE TAL PUNE DIST PUNE 2) ZORYA LAXMAN PAWAR AGE 35 AT. BHAVE ADHI WASHI WADI TAL MAHAD DIST RAIGAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
SACHIN SITARAM TIKHE ,SACHIN SITARAM TIKHE AGE 34 AT. JANTA VASAHAT PARVATI PUNE TAL PUNE DIST PUNE
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
:-
MAHAD MIDC POLICE STATION MOTOR ACCIDENT NO 27/2017
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.