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.
:-
NERAL POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO, 23/2017
4.
Date,Time And Place Of Accident
:-
2017-11-04 , 9: 35 , AT. POSHIR GAON DESTINATION COMPNY NERAL TAL KARAJAT
5.
Name of Injured/Deceased
:-
NAME OF INJURED - RAMDAS DATTATREY KABARI AT. POSHIR TAL KARJAT
6.
Name of the Hospital to Which He/She Was Removed
:-
RURAL HOSPITAL NERAL TAL KARJAT DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
MH 46 AQ 2095 , 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
:-
RAMDAS DATTATREY KABARI AT. POSHIR TAL KARJAT
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
RAMDAS DATTATREY KABARI,AT. POSHIR TAL KARJAT
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
:-
NERAL POLICE STATION MOTOR ACCIDENT NO 23/2017
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.