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FORM COMP AA
(See Rules 253c254c(lll)2s4(80 2ss(lXlV))
REPORT ABOUTTHE MOTAR VEHICLES ACCIDENTS
L. Name of the Police station Panchsa ni oolice station
tz no'rq tpc,27g.337.338. MV Act 184, 134(AXB)2 cR.NO./TAR NO./SDE NO.
3. DATE, TIME & Place of the
accident
LOIOZI\OL\/ 08.30 A.M. Gureghar Tal mahabalesnwar
4. Name of the injured /Deceased
Sanjay vitthal mankumare, age 40, r/o Bhuteghar, tal' -Jawn'
dict qetara
5. Name of HosPitalto which
he/she was removed
Bail air hospital panchgani/ Gitanjli hospital wal
WS Rppache motar cycle no. MH 01 AQ 52596. Number of vehicles & tYPe of
vehicle
7. Name & address of the driver
of the vehicle with Perticulars
or driving license of the said
driver & the addres of the said
driving license. The number of
badge on case of Public
service Vehicle & the address
of the issuing AuthoritY of the
said badge.
Vilas sreepati gole, age 37, R/O bhouse Tal'mana
Dist. - Satara
Driving licence - MH 02 20080144101
WS Rppacne motar cycle no. MH 01AQ 5259
Owner name - Dinesh P patil R/O Darvesh bld no' 5/ 4th floar
Room no.73
8. Name & address of the Owner
of the vehicle as it stands on
the date ofthe accident.
9. Name & address of the
insurance comPanY with
whom the vehicle was insured
with the divisional office of
the assurance comPanY.
WS Rppacfre motar cycle no. MH 01AQ 5259
10. Number of insurance PolicY/
insurance certificate & the
date of validitY of the
insurance policY/ insurance
certificate.
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