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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.
:-
POLADPUR POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT NO 54/2017
3.
Accident No.
:-
4.
Date,Time And Place Of Accident
:-
2017-10-13 , 17:30 , AT. CHOLAI GAON MUMBAI GOA HIGH WAY NO 66 ROAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - JAY RAM SINGH AGE 30 AT. NIMAHA TARIAARI TAHASIL KOTAR RITTARI SATANA STAT UTTARPR
6.
Name of the Hospital to Which He/She Was Removed
:-
GOVERNMENT HOSPITAL POLADPUR TAL POLADPUR DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
GJ 27 /9434 , TRUCK
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
:-
JAY RAM SINGH AGE 30 AT. NIMAHA TARIAARI TAHASIL KOTAR RITTARI SATANA STAT UTTARPRADESH
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
UNKNOWN,UNKNOWN
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
:-
POLADPUR MOTOR ACCIDENT NO 54/2017
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.