FORM COMP AA

[See Rules 253 & 254 (e) (iii) 254 (80 255 (1) (iv)]
REPORT ABOUT THE MOTOR VEHICLE ACCIDENT
1) Name of the Police Station Poladpur
2) CR No./TAR No./SDE No. 003/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-01-07
Accident Date and Time:- 2021-01-07 12:30:00
Accident Place:- AT. Mumbai-Goa Highway No. 66 Poladpur Village Bhairavnath Mandir Near Road Poladpur Raigad Maharashtra
4) Name of the injured/Deseased 1. Mulesh Mahadev Chathavekar 2. Praful Ramakant Pawar
5) Name of the hospital to which he/she was removed Not Fint
6) Name of vehicle and type of the vehicle 1. Riksha MH 06 Z 2696 2. Bike MH 06 BR 667
7) Name and address of the driver of the vehicle with particular or driving licence of the said driver and the address of the issuing authority of the said driving licence. The number of badge in case of public service vehicle and the address of the issuing authority of the said badge Driver Name:- 1. Mulesh Mahadev Chathavekar 2. Praful Ramakant Pawar
Driver's Address:- 1. AT Divil Poladpur Raigad Maharashtra 2. AT. Sahyadri Nagar Poladpur Raigad
Licence No:- Not Fint
Licence's Issuing Authority:- Not Fint
Badge No:- Not Fint
Badge's Issuing Authority:- Not Fint
8) Name and address of the owner of the vehicle as it stands on the date of accident Owner Name:- Not Fint
Owner's Address:- Not Fint
9) Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance company Insurance Company:- Not Fint
Insurance's Company Address:- Not Fint
Insurance Company Divisonal Office:- Not Fint
10) Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate Insurance Policy No:- Not Fint
11) Action taken, if any and the result thereof FIR Report
PN/ 753 S. A. Kshirsagar
Inspector of Police
Poladpur Police Station
N. B. - This form should accompany with all the necessary document viz. (1) I.R. (2) Panchanama (3) Medical certificate /Post Motern Report