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 Khalapur
2) CR No./TAR No./SDE No. 181/2021
3) Date, Time and place of the accident Case Reg. Date :- 2021-07-28
Accident Date and Time:- 2021-07-14 20:20:00
Accident Place:- AT. Gorthan Village Vavoshi Road Tel. Khalapur Dist. Raigad Maharashtra
4) Name of the injured/Deseased Dinesh Rajdev Yadav
5) Name of the hospital to which he/she was removed M. G. M Hospital Kamothe Mumbai
6) Name of vehicle and type of the vehicle Bick MH 46 Y 4889
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:- Unknown Driver
Driver's Address:- Unknown vehicle Driver Address
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
ASI/ V. M. Surve Mo. No. 8793321643
Inspector of Police
Khalapur 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