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 Revdanda
2) CR No./TAR No./SDE No. 002/2022
3) Date, Time and place of the accident Case Reg. Date :- 2022-01-08
Accident Date and Time:- 2022-01-07 20:30:00
Accident Place:- BHOIGHAR TO BORLI ROAD, BHOIGHAR GAON NEAR BAMANKUNDI, TAL-MURUD
4) Name of the injured/Deseased DEATH-1) JAGDISH MOTIRAM VANE, 2) JYOTSNA JAGDISH VANE, AT- KAJUWADI, TAL MURUD. ENJURED_1) ABHISHEKH CHANDRAKANT RAJAPKAR, AT- SONARPADA, NAVRATNA SOCIETY ROOM NO 2, DOMBIVALI EAST THANE.
5) Name of the hospital to which he/she was removed
6) Name of vehicle and type of the vehicle AUTO RIKSHWA MHO5DZ4082
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:- ABHISHEKH CHANDRAKANT RAJAPKAR
Driver's Address:- AT- SONARPADA, NAVRATNA SOCIETY ROOM NO 2, DOMBIVALI EAST THANE.
Licence No:- NIL
8) Name and address of the owner of the vehicle as it stands on the date of accident Owner Name:- NIL
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 CRIME REGISTER IPC 304(A),279.337,338, MVA 184
PSI CHIMDA REVDANDA PS
Inspector of Police
Revdanda 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