Claim Petition under MV Act

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 injuredMr. 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 thereofe.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 awarde.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.Prayere.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

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