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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.
:-
PALI POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 26/2017
4.
Date,Time And Place Of Accident
:-
2017-12-23 , 05:00 , AT. SHARD WADI GAON PALI BHIRA ROAD MANGAON ROAD TAL SUDHAGAD DIST RAIGAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - - 1) SUSHIL RAMMOHAN SING AGE 54 AT. SANDIP NAGAR SOC. 1 B 106 JAYPRAKASH NAGAR G
6.
Name of the Hospital to Which He/She Was Removed
:-
PHC PALI TAL SUDHAGAD DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 08 A G 2579 2) M H 06 B M 6741 , 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
:-
CHANDRAKANT BASANAN GULLAR AT. BHAGATSING NAGAR LIKE ROAD HANUMAN GALLI NO 1 GOREGAON WEST MUL AT. NERTHAM TAL MAKATAL DIST MEHABUBA NAGAR STAT. TELANGANA
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
KISHOR SADANAND EDAWANKAR ,AT. A 402 SALT LIGH GUNFAROAD JOGESHWARI MUMBAI 60
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
:-
PALI POLICE STATION MOTOR ACCIDENT NO 26/2017
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.