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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.
:-
MANGAON POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR . NO. 140/2017
3.
Accident No.
:-
4.
Date,Time And Place Of Accident
:-
2017-10-14 , 4:30 , AT. MANGAON GAON TILORE FATA MUMBAI GOA HIGH WAY ROAD
5.
Name of Injured/Deceased
:-
NAME TO INJURED - SWAPALANI ATISH GAVANE AT INDIPUR TAL MANGAON 2) MANISHA PARASHURAM UBHARE AT. DHA
6.
Name of the Hospital to Which He/She Was Removed
:-
SUB DIVISIONAL HOSPITAL MANGAON TAL MANGAON DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
M H 06 S 6784 , VIKRAM RIKSHA
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
:-
HARSHAL RAGHO GAIKAR AGE 30 AT. UCHEDE TAL PEN DIST RAIGAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
HARSHAL RAGHO GAIKAR ,AT. UCHEDE TAL PEN 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
:-
MANGAON POLICE STATION MOTOR ACCIDENT CR. NO. 140/2017
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.