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.
:-
KHOPOLI POLICE STATION
2.
CR No.
:-
3.
Accident No.
:-
MOTOR ACCIDENT NO 145/2017
4.
Date,Time And Place Of Accident
:-
2017-11-10 , 02:45 , AT. PUNE MUMBAI HIGH EXPRESS ROAD KM.42/600
5.
Name of Injured/Deceased
:-
NAME OF DECEASED - SUNIL SUBHASH PATIL AGE 31 AT. PILODE BRU. TAL YAVAL DIST JALGAON NAME OF INJUR
6.
Name of the Hospital to Which He/She Was Removed
:-
LOKMANYA HOSPITAL NIGADI DIST PUNE
7.
Number Of Vehical and type Of the Vehical
:-
1) M H 16 B H 6783 2) M H 45 -1396 , 1) CAR 2) TANKAR
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
:-
1) PARESH JAYKUMAR LUNKAD DL NO. MH 1620080020382 2) VALMIK RAMDAS SHINDE DL NO. MH 242015000788
9.
Name And Address Of the Owner Of the Vehical As It Stand On the Date Of Accident
:-
1) PARESH JAYKUMAR LUNKAD DL NO. MH 1620080020382 2) VALMIK RAMDAS SHINDE DL NO. MH 242015000788,1) PARESH JAYKUMAR LUNKAD DL NO. MH 1620080020382 2) VALMIK RAMDAS SHINDE DL NO. MH 242015000788
10.
Name And Address Of the Insurance Company With Whome the Vehical Was Insured And the Divisional Office Of the Said Insurance Company.
:-
1) CHOLA MS GENERAL INSURANCE 2) UNITED INDIAN INSURANCE CO. LTD , 1) A/P BURUDGAON MAREKET YARD PARISAR SARASNAGAR AHMEDNAGAR 2) KURDUWADI ROAD TEMBHURI DIST SOLAPUR , AHMDNAGAR 2) SOALPUR
11.
Number Of Insurance Policy/Insurance Certificate And the Date Of Validity Of the Insurance Policy/Insurance Certificate.
:-
1) CAR ECO - 3362/01365897/000/00 2) TANKAR NO 161,2018-05-21 , 2016-01-01
12.
Action Taken, If Any, And the Result thereof
:-
KHOPOLI POLICE STATION MOTOR ACCIDENT NO.145/2017
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.