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.
:-
KHALAPUR POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR, NO 254/2017
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2017-12-04 , 02:00 , AT. MUMBAI PUNE HIGH WAY ROAD KHALPUR TOLL NAKA 1 TO 1.5 KM
5.
Name of Injured/Deceased
:-
NAME OF DECEASED -RATAN VASATN RAJPUT AT. SANGHARSH SOCIETY NO 5 ROOM NO 1 GHODPDEV KALACHAIKI MUMBA
6.
Name of the Hospital to Which He/She Was Removed
:-
PHC KHALAPUR TAL KHALAPUR DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
MH 43 U 9155 , TEMPO
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
:-
ANKIT DEVENDRA SING AT. PARK SIDE VIKROLI MUMBAI MUL AT. BAIRAJRAMPUR TAL JONPUR DIST JONPUR 2) ASRAM POPAT DAHIPALE AT. ROOM NO 3/05 CHATAI CHAL KALA CHAIKI CHINPOKALI MUMBAI 15 MUL AT. POST KAREGAON TAL PATHARDI DIST AHAMADNAGAR D L NO MH 1620090015152
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
RATAN VASATN RAJPUT ,AT. SANGHARSH SOCIETY NO 5 ROOM NO 1 GHODPDEV KALACHAIKI MUMBAI
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 254/2017
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.