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.
:-
TALA POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 04/2017
4.
Date,Time And Place Of Accident
:-
2017-12-26 , 16:00 , AT. KHAMBAWALI GAON TAL TO MANDAD ROAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - 1) ATIB MEHAMUD KHERTKAR 2) MADINA SAJJAD KHERTKAR AGE 30 BOTH AT. KUDA TALA TALUK
6.
Name of the Hospital to Which He/She Was Removed
:-
P H C ,TALA TALUKA TALA DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
M H 06 B B 7648 , PANJO RISKSHA
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
:-
JAVED IBRAHIM KARADEKAR AT MET MOHALLA TAL TALA DIST RAIGAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
JAVED IBRAHIM KARADEKAR ,AT MET MOHALLA TAL TALA DIST RAIGAD
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
:-
TALA POLICE STATION MOTOR ACCIDENT NO 4/2017
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.