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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.
:-
KARJAT POLICE STATION
2.
CR No.
:-
MOTOR ACCIDETN CR NO 82/2018
3.
Accident No.
:-
NULL
4.
Date,Time And Place Of Accident
:-
2018-05-07 , 23:17 , AT. KOTHIBE GAON PULA NEAR TALUKA KARAJT
5.
Name of Injured/Deceased
:-
NAME OF DECEASED -DIPAK SHANKAR BANGARE AGE 24 AT.NAGYACHI WADI POST PATRAJ TALUKA KARAJT DISTRICT R
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
:-
1) M H 05 / 9949 2) M H 06 A Y 6503 , 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
:-
KETAN CHANDRAKANT FASAL AT . DHOTRE TALUKA KARAJT DISTRICT RAIGAD 2) DIPAK SHANKAR BANGARE AGE 24 AT.NAGYACHI WADI POST PATRAJ TALUKA KARAJT DISTRICT RAIGAD
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
KETAN CHANDRAKANT FASA,L AT . DHOTRE TALUKA KARAJT DISTRICT RAIGAD
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
:-
KARJAT POLICE STATION MOTOR ACCIDENT CR NO 82/2018
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.