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.
:-
MAHAD CITY POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR NO 06/2018
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2018-01-07 , 4:25 , AT. GANDHARPALE GAON MUMBAI GOA HIGH WAY ROAD BODDHA LENI
5.
Name of Injured/Deceased
:-
NAME OF DECEASED PERSON - YOGESH DIGMBAR KHORJUVEKAR AGE 27 AT. 1260 DANDI MARKEBAG DISRT SINDHUDURG
6.
Name of the Hospital to Which He/She Was Removed
:-
RURAL HOSPITAL NERAL TAL KARJAT DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 46 A F 6671 2) M H 05 B J 2586 , 1) TRAILER 2) 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
:-
SANDIP LALA SURYAWANSHI AT. SATARA
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
:-
MAHAD CITY POLICE STATION MOTOR ACCIDENT CR. NO 06/2018
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.