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 Mhasla
2) CR No./TAR No./SDE No. 059/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-07-27
Accident Date and Time:- 2021-07-27 19:15:00
Accident Place:- AT. Mangaon Mhasla Road HP Gas Agency Mhasla at front side Mhasla Dist. Raigad Maharashtra
4) Name of the injured/Deseased Tejas Anil Dhavle
5) Name of the hospital to which he/she was removed None
6) Name of vehicle and type of the vehicle Bick MH 06 BZ 0486
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:- Anil Dhansing Rathod
Driver's Address:- AT. Fanse Chawl Kanya Highschool at front side Mhasla Dist. Raigad
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 1303 S. N. Jadhav Mo. No. 9823514051
Inspector of Police
Mhasla 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