Claim Petition under MV Act’s format is hereby given below.
BEFORE THE MOTOR ACCIDENT CLAIMS TRIBUNAL_________
CLAIM PETITION NO. __________ OF 20XX
IN THE MATTER OF:
Mr. ABC CLAIMANT
VERSUS
1.XYZ RESPONDENT 1
(DRIVER)
2.LMN RESPONDENT 2
(OWNER)
3.______ Insurance Company Ltd RESPONDENT 3
(INSURANCE COMPANY)
POLICE STATION: _______________
APPLICATION FOR PAYMENT OF COMPENSATION UNDER SECTION 140 AND 166 OF MOTOR VEHICLES ACT, 1988
| 1. | Name and Father’s Name of the Person injured | Mr. ABCs/o Mr. ______ |
| 2. | Full address of the Person injured | |
| 3. | Age of the Person injured | |
| 4. | Occupation of the Person injured | |
| 5. | Name & Address of the Employer of the injured | |
| 6. | Monthly Income of the person injured | |
| 7. | Does the person in respect of whom compensation is claimed pay income tax? If so state the amount of income tax | |
| 8. | Place, date and time of accident | |
| 9. | Brief particulars of the accident | |
| 10. | Name and address of the Police station in whose jurisdiction accident took place or was registered | |
| 11. | Was the person in respect of whom compensation is claimed traveling by the vehicle involved in the accident? If so give the name and place of starting the journey and destination | |
| 12. | Nature of Injuries sustained and disablement, if any, caused | |
| 13. | Name and address of the Medical Officer/ Practitioner, if any who attended the injuries | |
| 14. | Period of treatment and expenditure if any incurred | |
| 15. | Registration Number and type of vehicle involved in the Accident | |
| 16. | Name and Address of the owner of the vehicle | |
| 17. | Name and address of Driver of the Offending Vehicle | |
| 18. | Name and address of the insurer of the vehicle | |
| 19. | Has any claim been lodged with the owner, insure if so, by the Applicant with what result | |
| 20. | Name and Address of the Applicant | |
| 21. | Relationship with diseased | |
| 22. | Title of the Property of the deceased | |
| 23. | Amount of Compensation claimed and basis thereof | e.g. Pecuniary loss of earning, Medical Expenses, Loss on account of Mental agony etc.. |
| 24. | Whether reports from the police and Registering Authority have been obtained in Form “A” and Form “D” (If so, to be annexed) | |
| 25. | Whether affidavit of the Applicant and witnesses as per rule 8 are annexed (give details) | |
| 26. | Whether documents mentioned in Rule 8 are being annexed duly indexed (give details) | |
| 27. | Any other information that may be necessary and helpful in the disposal of the case |
PART II
(To be filled if prayer is made for interim award)
| 28. | Amount of compensation claimed as interim award | |
| 29. | Reason for claim of interim award | e.g. claimant is bedridden etc |
| 30. | Whether documents mentioned in sub-rule (4) and sub-rule (5) of rule 20 have been annexed (give details) | |
| 31. | Prayer | e.g. It is therefore most respectfully prayed that the Petitioner may be awarded a compensation of Rs. ; andIf is further, most respectfully prayed that the Claimants may be awarded compensation under Section 140 of the Motor Vehicles Act, 1988.Any other or further relief as this Hon’ble Tribunal may deem fit and proper in the facts and circumstances of the case as may be made. |
PETITIONER
THROUGH
______________
(Advocate)
Place: ____
Date: _____
VERIFICATION
I, ABC, the above named claimant do hereby verify that the contents of Para 1 to 31 of the Claim Petition are true and correct to the best of my knowledge and belief and those of legal averments are true and correct on the basis of legal advice received and believed to be true by me. The last para is the prayer to this Hon’ble Tribunal.
Verified at _________ on this _____ day of _______ 20XX.
PETITIONER