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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.
:-
WADKHAL POLICE STATION
2.
CR No.
:-
MOTOR ACCIDETN CR NO 53/2018
3.
Accident No.
:-
__
4.
Date,Time And Place Of Accident
:-
2018-05-16 , 00:54 , AT. DEVALI GAON MUMBAI TO GOA HIGH WAY ROAD
5.
Name of Injured/Deceased
:-
NAME OF INJURED - 1) DIPAK RAMCHANDRA MUTRISHI AGE 43 AT. PRIMIYAM PARK PARAS MANI BULDING C 101 VI
6.
Name of the Hospital to Which He/She Was Removed
:-
SUB DIVISIONAL HOSPITAL TAL PEN DIST RAIGAD
7.
Number Of Vehical and type Of the Vehical
:-
1) MH-48-F-2703 2) MH-08-W-3013 , 1) CAR 2) PIC UP CAR
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
:-
KIRAN DHANJAY BAIKAR AT. ROOM NO. 305 OMKAR NIWAS SAMIL PADA LITTILE FLOWER SCHOOL NEAR NALASOPARA WEST
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
1) DIPAK RAMCHANDRA MUTRISHI AGE 43 2) RIYAJ SAIKAT SASURKAR AGE 36 , AT. PRIMIYAM PARK PARAS MANI BULDING C 101 VIRAR WEST BORIJ ROAD ON THE WAY HOTEL BACK SIDE 2) AT.
10.
Name And Address Of the Insurance Company With Whome the Vehical Was Insured And the Divisional Office Of the Said Insurance Company.
:-
BAJAJ INSURANCE , AT. 1st FLOOR B WING PLAZA ARIPORT YERAVANDA PUNE , AT. PUNE
11.
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate.
:-
OG -18-1934-18303-0000-1828,2018-06-15 , 2017-06-16
12.
Action Taken, If Any, And the Result thereof
:-
WADAKHAL POLICE STATION MOTOR ACCIDENT CR NO 53/2018
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.