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 Mangaon
2) CR No./TAR No./SDE No. 006/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-01-02
Accident Date and Time:- 2021-01-02 21:00:00
Accident Place:- AT Mumbai-Goa Highway Road Gangewadi Stop Mangaon , Raigad
4) Name of the injured/Deseased 1. Ram Jhil Modhke 2. Abhijit Gajanan Madhavi
5) Name of the hospital to which he/she was removed Not Fint
6) Name of vehicle and type of the vehicle Bike MH 30 T 1695
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:- Abhijit Gajanan Madhavi
Driver's Address:- AT. Utekhol , Mangaon , 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
MPN/ 190 Salunkhe
Inspector of Police
Mangaon 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