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.
:-
KOLAD POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 28/2017
4.
Date,Time And Place Of Accident
:-
2017-12-16 , 07:50 , AT. VARASAGAON STOP MUMBAI GOA HIGH WAY ROAD TAL ROHA
5.
Name of Injured/Deceased
:-
NAME OF INJURED - VINAYAK DASU GADAM AT. KALAM PLAZA BULDING KOLAD TAL ROHA
6.
Name of the Hospital to Which He/She Was Removed
:-
PHC AMBEWADI KOLAD TAL ROHA DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 43 A J 4786 2) M H 06 Y 6790 , 1) CAR 2) MOTOR CYCLE
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
:-
RAJENDRA DADARAO HAKE AT. NO 25 SAI CHAL ROAD NO 28/34 HAMUMAN NAGAR WAGALE EASTE DIST THANE
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
RAJENDRA DADARAO HAKE,AT. NO 25 SAI CHAL ROAD NO 28/34 HAMUMAN NAGAR WAGALE EASTE DIST THANE
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
:-
KOLAD POLICE STATION MOTOR ACCIDENT NO 28/2017
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.