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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.
:-
KHOPOLI POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR NO 247/2017
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2017-12-05 , 13:30 , AT. PUNE MUMBAI HIGH WAY ROAD ADOSHI GAON KM 37/300 KHALAPUR TAL KHALAPUR DIST RAIGAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - ASHWINI MANGESH PRABHALE AGE 30 AT. DANGE CHOUK THERAGAON PUNE 2) PALLAVI SAGAR PR
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 09 D A 3525 2) M H 43 B J 1417 , 1) CAR 2) CANTRAINER
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
:-
UMESH BAGALRAO HERALEKAR AGE 47 AT. HERALO TAL HATKANGALE DIST KOLHOAPUR
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
UMESH BAGALRAO HERALEKAR ,AT. HERALO TAL HATKANGALE DIST KOLHOAPUR
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
:-
KHOPOLI POLICE STATION MOTOR ACCIDENT CR. NO. 247/2017
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.