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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.
:-
GOREGAON POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 01/2018
4.
Date,Time And Place Of Accident
:-
2018-01-26 , 07:30 , AT. WADAPALE GAON EKVIRA HOTEL SHEJARI MUMBAI GOA HIGH WAY ROAD TALUKA MANGAON
5.
Name of Injured/Deceased
:-
NAME OF INJURED - 1) BABU RAM SHAHU AGE 40 AT, INDIRA NAGAR ZOPADPATTI GALLI NO 2 TO FIT ROAD MANKHU
6.
Name of the Hospital to Which He/She Was Removed
:-
PHC GOREGAON TAL MANGAON DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 46 A R 6183 2) M H 46 A R 6183 , 1) TRUCK 2) DUMMER
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
:-
1) BABU RAM SHAHU AGE 40 AT, INDIRA NAGAR ZOPADPATTI GALLI NO 2 TO FIT ROAD MANKHUDA MANDALA MUMBAI 43 MUL AT. RAMMOLA THANE – MAHARAJ GANJ TALUKA BADALAPUR DISRT JAINPUR STAT. UTTARPRADESH
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
:-
GOREGAON POLICE STATION MOTOR ACCIDETN NO 01/2018
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.