Form of Claim Petition Accidents Claims Tribunal
To
The Motor Accidents Claims Tribunal,
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I . . . . . . . . . . . . . . . . . . . . . . son/daughter/widow of . . . . . . . . . . . residing at . . . . . . . . . . . having been injured in a motor vehicle accident hereby apply for the grant of compensation for the injury sustained. Necessary particulars in respect of the injury, vehicle etc. are given below:
I . . . . . . . . . . . son/daughter/wife/widow of . . . . . . . . . . . residing at . . . . . . . . . . . . . . hereby apply as a legal representative/agent, for the grant of compensation on account of death of/injury sustained by Shri/Kumari/Shrimati . . . . . . . . . . . son/daughter/wife/widow of Shri/Shrimati . . . . . . . . . . . who died/was injured in a motor vehicle accident. Necessary particulars in respect of the deceased/injured and the vehicle etc., are given below:
1. Name and Father’s name of the person injured/dead (husband’s name in case of married woman and widow).
2. Full address of the person injured/dead.
3. Age of the person injured/dead.
4. Occupation of the person injured/dead.
5. Name and address of the employer of the deceased, if any.
6. Monthly income of the person injured/dead.
7. Name and age of each of the dependants of the deceased/injured indicating relationship with him, and also monthly average income of the deceased/injured and the source of such income.
8. Does the person in respect of whom compensation is claimed pay income tax? If so, state the amount of income tax (to be supported by documentary evidence).
9. Place, date and time of the accident.
10. Name and address of police station in whose jurisdiction the accident took place or was registered.
11. Was the person in respect of whom compensation is claimed travelling by the vehicle involved in the accident? If so, give the names of places of starting of journey and destination.
12. Nature of injuries sustained.
13. Name and address of the Medical Officer/Practitioner, if any, who attended on the injured/dead.
14. Period of treatment and expenditure, if any, incurred thereon (to be supported by documentary evidence).
15. Registration number and the type of the vehicle involved in accident.
16. Name and address of the owner of the vehicle.
17. Name and address of the insurer of the vehicle.
18. Has any claim been lodged with the owner/insurer ? If so, with what result ?
19. Name and address of the applicant.
20. Relationship with the deceased.
21. Title to the property of the deceased.
23. Any other information that may be necessary or helpful in the disposal of the claim.
I, . . . . . . . . . . . solemnly declare that the particulars given above are true and correct to the best of my knowledge.
Signature or thumb-impression
of the applicant.
