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.
:-
KHALAPUR POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR NO 12/2018
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2018-01-09 , 09:45 , AT. SAVAROLI GAON MUMBAI TO PUNE HIGH WAY ROAD SAVROLI TOLL NAKKA 1 KM
5.
Name of Injured/Deceased
:-
NAME OF INJURED - RIJWAN SOYABA CHOUDHARI AGE 18 AT. LUITWADI THANE 2) NILESH RAJ ASHOKKUMAR THAKUR
6.
Name of the Hospital to Which He/She Was Removed
:-
MGM Hospital Kalmboli new panvel
7.
Number Of Vehical and type Of the Vehical
:-
1) R J 21 C B 0833 2) M H 04 J F 9700 , 1) CAR 2) TEMPO
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
:-
FAIJAN PARENAGORI SHAIKH AGE 19 AT. KAJUPADA DERY BURUJ MUKADAM CHAL PAPAI ROAD KURLA WEST
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
:-
KHALAPUR POLICE STATION MOTOR ACCIDENT CR NO 12/2018
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.