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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.
:-
KHALAPUR POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 103/2017
4.
Date,Time And Place Of Accident
:-
2017-11-28 , 11:00 , AT. TEMBHARI GAON PUNE MUMBAI KM 21/600 TAL KHALAPUR
5.
Name of Injured/Deceased
:-
NAME OF INJURED - SHAHAJI SHIVAJI BARVADE AGE 28 AT. MAVALWADI TAL HAVELI DIST PUNE
6.
Name of the Hospital to Which He/She Was Removed
:-
MGM Hospital Kalmboli new panvel
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 42 M 1930 2) M H 46 N 2701 , 1) TEMPO 2) CAR
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
:-
SHAHAJI SHIVAJI BARVADE AGE 28 AT. MAVALWADI TAL HAVELI DIST PUNE
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
SHAHAJI SHIVAJI BARVADE ,AT. MAVALWADI TAL HAVELI 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
:-
KHALAPUR POLICE STATION MOTOR ACCIDENT NO 103/2017
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.