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 Khopoli
2) CR No./TAR No./SDE No. 281/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-07-28
Accident Date and Time:- 2021-07-28 16:45:00
Accident Place:- AT. Old Mumbai- Pune Highway Tata Pawar House Near Saymal Village Khopoli Tel. Khalapur Dist. Raigad Maharashtra
4) Name of the injured/Deseased None
5) Name of the hospital to which he/she was removed None
6) Name of vehicle and type of the vehicle Truck MH 46 AF 4163
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:- Shripal Vijay Pratap Shing
Driver's Address:- AT. Uttar Pradesh
Licence No:- None
8) Name and address of the owner of the vehicle as it stands on the date of accident Owner Name:- None
9) Name and address of the insurance company with whom the vehicle was insured and the divisional office of the said insurance company
10) Number of Insurance policy/Insurance certificate and the Date of validity of the insurance Policy/Insurance certificate
11) Action taken, if any and the result thereof FIR Report
PN / 1386 Dhaigude Mo. No. 8888856911
Inspector of Police
Khopoli 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