In the Court of the Motor Accident Claims Tribunal Ranchi

                                                                                 Claim Petition No. _______

 

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  Petitioner

 

                                                VERSUS

 

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  Respondent

 

Application under the Section 166 & 140 of the

Motor Vehicle Act 1988 for grant of Compensation

 

Sir,

 

1.          Name & Father’s Name of the person

          injured/dead (Husband’s Name in case

          of married women & 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 & address of the employer of

          the injured / dead.                                        :

 

6.          Monthly income of the person injured/

          dead.                                                      :                                                                                                                        

 

7.          Does the person in respect of whom

          compensation is claimed pay income

          tax? If so state the amount of the

          income tax (to be supported by document)      :

 

 

8.          Place, date and time of accident                 :

 

9.          Name & Address of Police Station in

          whose jurisdiction the accident took

          place & FIR was registered.              :

 

10.          Was the person in respect of whom

          compensation is claimed traveling by  

          the  vehicle   involved  in  the accident ?

          If so, give  the name & place of starting

          the  journey  and destination.             :

 

11.          Nature of the injuries sustained.               :

 

12.          Name & Address of the Medical

          Officer/Practitioner, if any who

          attended to the injuries.                             :

 

13.          Period of treatment and expenditure.          :

 

14.          Registration No. & Type of vehicle

          involved in accident.                          :

 

15.          Name & address of the owner of

          offending vehicle.                                       :

 

16.          Name & address of the driver of

          offending vehicle.                                       :

 

 

17.          Name & address of the insurer of 

          the vehicle.                                                 :

 

18.          Has any claim been lodged with

          the owner/insurer, if so, with what

          result.                                                   :

 

19.          Name & address of the applicant.      :

 

 

20.          Relationship with the deceased /

          injured.                                                  :

 

21.          Title of the property of the deceased/

          injured.                                                  :

 

22.          Amount of compensation claimed.       :

 

23.          Any other information that may be

          necessary and helpful in the disposal

          of the case.                                          :

 

 


 

24.          Prayer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Petitioner

Verification:

 

Verified at Ranchi on this the ________ day of _________ 200__  that the contents of the above application are true and correct to my knowledge and belief.

 

Petitioner

 

 

 

 

 

Following documents should accompany the petition:-

 

1. Copy of the FIR registered in connection with said accident, if any.

2. Copy of the MLC/Post Mortem Report/Death Report as the case may be.

3. The documents of the identity of the claimants and of the deceased in a death case.

4. Original bills of expenses incurred on the treatment alongwith treatment record.

5. Documents of the educational qualifications of the deceased, if any.

6. Disability Certificate, if already obtained, in an injury case.

7. The proof of income of the deceased/injured.

8. Documents about the age of the victim.

9. The cover note of the third party insurance policy, if any.

10. An affidavit in support of the above documents and detailing the relationship of the claimants with the deceased.