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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.
:-
Alibag Police Station
2.
CR No.
:-
MOTOR ACCIDENT CR NO 76/2018
3.
Accident No.
:-
--
4.
Date,Time And Place Of Accident
:-
2018-06-01 , 01:14 , At. Karle Khindit Alibag Poynad Road Turn
5.
Name of Injured/Deceased
:-
NAME OF INJURED - Harishankar Nanaprasad Dube At. Valsad Stat. Gujarat
6.
Name of the Hospital to Which He/She Was Removed
:-
Sathe Hospital Alibag Taluka Alibag District Raigad
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 14 B T 2208 2) G J 15 C J 6619 , 1) S T BUS 2) 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
:-
Harishankar Nanaprasad Dube At. Valsad Stat. Gujarat
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
Asamita Umesh Bhartaya,At. Killa pardi Taluka Killa paredi District Balsad Stat. Gujarat
10.
Name And Address Of the Insurance Company With Whome the Vehical Was Insured And the Divisional Office Of the Said Insurance Company.
:-
Icici Lombard General Insurance Company , Icici Lombard General Insurance Company AT. Gujarat , At. Gujarat
11.
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate.
:-
3001/HI /1061/1369/00/000,2018-10-26 , 2017-10-27
12.
Action Taken, If Any, And the Result thereof
:-
ALIBAG POLICE STATION MOTOR ACCIDENT CR NO 76/2018
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.