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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.
:-
KOLAD POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR NO 67/2017
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2017-12-17 , 16:15 , AT. PUI GAON MUMABI GOA HIGH WAY ROAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - ASHOK DHONDU DISALE AT. PUI POST KOLAD TAL ROHA DIST RAIGAD
6.
Name of the Hospital to Which He/She Was Removed
:-
PUROHIT HOSPITAL PANVEL TAL PANVEL DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 12 L P 2257 2) M H 06 A D 7158 , 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
:-
1) MUKESH PURSHOTTAM KIR AT. 29/B/29 RATANDIP COLONY BHAICHAND TEQTAIL FRONT LVS MARG BHANDUP WEST MUMBAI MUL AT. MIRA PATIL WADI POST JAKIMIRA TALRATANAGIRI DIST RATANAGIRI 2) ASHOK DHONDU DISALE AT. PUI POST KOLAD TAL ROHA DIST RAIGAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
MUKESH PURSHOTTAM KIR,AT. 29/B/29 RATANDIP COLONY BHAICHAND TEQTAIL FRONT LVS MARG BHANDUP WEST MUMBAI MUL AT. MIRA PATIL
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 67/2017
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.