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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.
:-
PALI POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 24/2017
4.
Date,Time And Place Of Accident
:-
2017-12-10 , 21:40 , AT. PEDALI TAL SUDHAGAD GAON SBI BANK NEAR CHANDRKANT PATIL HOME
5.
Name of Injured/Deceased
:-
NAME OF INJURED - 1) BABAN LAXMAN PAWAR AGE 22 2) SHABI LAXMAN PAWAR AGE 40 3) ASHAVINI BABAN PAWAR
6.
Name of the Hospital to Which He/She Was Removed
:-
PHC PALI TAL SUDHAGAD DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 05 B H 4903 2 , 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
:-
SHRIKANT SALVALARAM SHELAKE AT. SHRIDKRUSHAN NAGAR RAHIWASI SANGH ROOM NO 91/1 KAKA RAND WADALA MUMBAI MUL AT. BHALVANI TAL KHANAPUR DIST SANGALI D L NO M H 01 20110028908
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
RAJESH LAXMAN NANGAONKAR ,AT. 23/1656 ASHIDAR NAGAR KALA CHAIKI MUMBAI
10.
Name And Address Of the Insurance Company With Whome the Vehical Was Insured And the Divisional Office Of the Said Insurance Company.
:-
MISOCO TOKYTO COMPANY , AT,. MUMBAI , AT. MUMABAI
11.
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate.
:-
87412363,2017-12-31 , 2016-01-01
12.
Action Taken, If Any, And the Result thereof
:-
PALI POLICE STATION MOTOR ACCIDENT NO 24/2017
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.