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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.
:-
POYNAD POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 14/2017
4.
Date,Time And Place Of Accident
:-
2017-11-26 , 14:35 , AT. KARMALE KHINDIT TAL ALIBAG
5.
Name of Injured/Deceased
:-
NAME OF INJURED - NITIN LAXMAN THAKUR AGE 48 2) ANAMIKA NITIN THAKUR AGE 40
6.
Name of the Hospital to Which He/She Was Removed
:-
PRAYAS HOSPITAL ALIBAG DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 01 B K 4499 2) M H 06 B A 2421 , 1) CAR 2) 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
:-
DHARMENDRA BHAGWAN JUIKAR AGE 48 AT KOPAR POST KARMALE ALIBAG TAL ALIBAG DIST RAIGAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
DHARMENDRA BHAGWAN JUIKAR,AT KOPAR POST KARMALE ALIBAG TAL ALIBAG DIST RAIGAD
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
:-
POYNAD POLICE STATION MOTOR ACCIDENT 14/2017
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.