Export a Table to PDF Template | PrepBootstrap '); popupWin.document.close(); }

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.
:-
POLADPUR POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDETN NO 16/2018
4.
Date,Time And Place Of Accident
:-
2018-03-10 , 17:12 , AT. DHAMANI GAON MUMBAI TO GOA NO 66 ROAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - ROAD 1) SUNILKUMAR RAMSAFAL YADAV AT. SANGIPURI UP 2) MOINUDDIN AKBAR SHARWAN AT
6.
Name of the Hospital to Which He/She Was Removed
:-
GOVERNMENT HOSPITAL POLADPUR TAL POLADPUR DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
M H 11 B L 6861 2) M H 46 F 2851 , 1) TRUCK 2) TRANKAR
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
:-
SUNIL SITARAM GOTAD AT. ROOM NO 18 NISARG SOCITY 145 NEW MHADA COLONY PAWAR NAGAR THANE MUL AT. POST KARNBELE GOTAWADI TALUKA SAGAMESHWAR DISTRICT RATANAGIRI
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
SUNIL SITARAM GOTAD,AT. ROOM NO 18 NISARG SOCITY 145 NEW MHADA COLONY PAWAR NAGAR THANE MUL AT. POST KARNBELE GOTAWADI T
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
:-
POLADPUR POLICE STATION MOTOR ACCIDENT NO 16/2018
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.