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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 255/2017
3.
Accident No.
:-
4.
Date,Time And Place Of Accident
:-
2017-12-15 , 02:15 , AT. PUNE MUMBAI HIGH WAY ROAD DASTURI GAON KM 40/700 TAL KHALAPUR DIST RAIGAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - 1)VANDANA MOHAN BALKHANDE AGE 44 2) SUMESH MOHAN BALKHANDE AGE 22 3) NITA GIRISH P
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 43 A N 4964 2) M H 14 D X 9229 , 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
:-
1) MOHAN TUKARAM BALKHANDE AGE 50 AT. ROOM NO 302 A WING BULDING B 5 GITANJALI SOCIETY SECTOR NO 10 KALMBOLI TAL PANVEL DIST RAIGAD MUL AT. CHAFANATH TAL KAMAMNURI DIST HINGOLI 2) mangesh ashok tope waki bu tel khed
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
Access platform pvt ltd 2) ASHOK SHANKAR POTE ,KHOPOLI POLICE STATION MOTOR ACCIDENT NO 255/2017
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 255/2017
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.