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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.
:-
KHOPOLI POLICE STATION
2.
CR No.
:-
MOTOR ACCIDENT CR.NO. 218/2017
3.
Accident No.
:-
4.
Date,Time And Place Of Accident
:-
2017-10-27 , 07:00 , AT. KHARVAI PO JAMBRUG KHOPOLI TAL KHALAPUR
5.
Name of Injured/Deceased
:-
SURAJ HANUMANG MINCHAND AT. KHARVAI PO JAMBRUG KHOPOLI TAL KHALAPUR
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
:-
M H 46 A Y 4364 , MOTOR CYCLE
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
:-
CHETAN VINAYAK KARNUK BIDKHURD AT JAMBRUG TAL KHALAPUR DIST RAIGAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
CHETAN VINAYAK KARNUK ,AT BIDKHURD JAMBRUG TAL KHALAPUR 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.
:-
ICIC LOMBAED GANRAL ASSURANCE CO.LTD , NEW LINK ROAD MALAD WEST MUMBAI , MUMBAI
11.
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate.
:-
3005/A1 11304227/00000 24/02/2018 ,2018-02-24 , 1970-01-01
12.
Action Taken, If Any, And the Result thereof
:-
KHOPOLI POLICE STATION MOTOR ACCIDENT CR.NO 218/2017
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.