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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 28/2017
4.
Date,Time And Place Of Accident
:-
2017-12-30 , 19:30 , AT. WAKAN TO PALI ROAD RABGAON
5.
Name of Injured/Deceased
:-
NAME OF INJURED - NIL
6.
Name of the Hospital to Which He/She Was Removed
:-
NIL
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 02 D J 9729 2) M H 46 F 1616 , 1) CAR 2) 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
:-
RAJESH SHANKAR SHIHNDE AT. 104 B SAI DHAM SOCIETY MAJAS WADI JOGESHWARI PRUV MUMBAI NO 60
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
RAJESH SHANKAR SHINDE ,AT. 104 B SAI DHAM SOCIETY MAJAS WADI JOGESHWARI PRUV MUMBAI NO 60
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 General Insurance Company Ltd. , GE Plaza, Airport Road, Yerawada, Pune 411 00 , PUNE
11.
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate.
:-
OG 17-1934-1801- 00065291,2018-02-25 , 2017-01-24
12.
Action Taken, If Any, And the Result thereof
:-
PALI POLICE STAITO MOTOR ACCIDENT NO
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.