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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.
:-
MAHAD CITY POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR, NO 83/2017
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2017-12-12 , 11:00 , AT. MUMBAI GOA HIGH WAY ROAD RELINCE PEPTROL PUMP
5.
Name of Injured/Deceased
:-
NAME OF INJURED - YUGESH LAXMIKANT SANSARE AGE 41 2) NIDHI YUGESH SANSARE AGE 14 AT AT. KUMBHAR ALI
6.
Name of the Hospital to Which He/She Was Removed
:-
RANADE HOSPITAL MAHAD TAL MAHAD DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) MH 06 DK 3358 2) MH 01 NA 8440 , 1) ACTIVE SCOOTY 2) JEEP
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
:-
YUGESH LAXMIKANT SANSARE AGE 41 AT. KUMBHAR ALI TAL MAHAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
YUGESH LAXMIKANT SANSAR,AT. KUMBHAR ALI TAL MAHAD
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
:-
MAHAD CITY POLICE STATION MOTOR ACCIDENT CR.NO 83/2017
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.