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.
:-
KHALAPUR POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR NO 266/2017
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2017-12-20 , 09:30 , AT. PUNE MUMBAI HIGH WAY ROAD KUNBHIWAI GAON 31/200 KM TAL KHALAPUR
5.
Name of Injured/Deceased
:-
NAME OF INJURED - SUBHAM GORKHANATH BORADE 2) ASMIT SUHAS TAVADE AT. MUMBAI 3) ANANT NARENDRA PARIKH
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 04 PJ 0423 2) M H 12 FP 1185 , 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
:-
MOHAMAMAD ADIL SHAHA ROOM NO 308 3RD FLOOR SAI SHARDHA CO OP SOCIETY VASTSALATAI NAIK NAGAR CST ROAD CHEMBUR MUMABI D L NO MH 03 20170044840 2) ANANDT NARESNDRA PAREKHA AT. SAMBHAJI NAGAR DHANKAWADI PUNE
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
MOHAMAMAD ADIL SHAHA ROOM NO 308 3RD FLOOR SAI SHARDHA CO OP SOCIETY VASTSALATAI NAIK NAGAR CST RO,MOHAMAMAD ADIL SHAHA ROOM NO 308 3RD FLOOR SAI SHARDHA CO OP SOCIETY VASTSALATAI NAIK NAGAR CST RO
10.
Name And Address Of the Insurance Company With Whome the Vehical Was Insured And the Divisional Office Of the Said Insurance Company.
:-
BAJAJ ALLIANZ GENRAL INSURANCE CO LTD , 952/954 APPA SAHEB MHATRE MARGE PRABHADEVI NR CHETANYA TWR NEXT TO SARAWANT BHAVAN DADAR MUMBAI 25 , MUMBAI
11.
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate.
:-
---,2018-04-24 , 2016-01-01
12.
Action Taken, If Any, And the Result thereof
:-
KHALAPUR POLICE STATION MOTOR ACCIDENT CR, NO 266/2017
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.