Accident Death Claim Affidavit Format[CD1] 

 

 

BEFORE THE _____ CLAIMS TRIBUNAL, ____

 

1-        Ram.............................

 

2-        wife of ………………………..

 

 

3-        son of ………………………

 

 

2-……………………………….  s/o………………………….  D/o…………………………  s/o…………………………………….

 

All residents of _____  District ___  at present R/o _____

.

…………………………………………………………..PETITIONERS

 

VERSUS

 

1-………………………………….

s/o ……………………….

 

Resi……………………………_

 

(Driver of the offending vehicle ____ No. ____)

 

2- ____  son of ____  resident of ____ (Owner of the offending vehicle ____ No. ____)

 

_____ vide its Insurance Policy No. …………..valid upto ………….. issued from ____ branch office service may be effected through its Branch Manager at ____.

 

(Insurer of the offending vehicle ………………. No. ……………….)

 

 

………………………………………………………..RESPONDENTS

 

 

 

CLAIM PETITION UNDER SECTION ___ OF THE MOTOR VEHICLE ACT FOR GRANT OF COMPENSATION OF ____/- UNDER NO FAULT LIABLITY UNDER SECTION ___ OF ____

 

Sir

The petitioners most respectfully submit as under:-

 

We, the above-named petitioners being the legal heirs/representatives of deceased ____, do hereby apply for the grant of compensation, who died in the roadside vehicular accident caused by the respondent No.1 by driving the vehicle ____ rashly, negligently, carelessly, without observing the traffic rules, without observing the safety of the others at ____ within the jurisdiction of ____ on ____ at about ____.

The necessary particulars in respect of the vehicle, deceased etc. are given herein below:-

1-      Name & father’s name of the person deceased – ____..........................................son of ____.....................

2-      Full address of the person deceased – ____Resi……………………

 

3-      Age of the person deceased –

 

4-      Occupation of the person died – ____

 

5-      Name and address of employer – ____

 

 

6-      Monthly income of the person – ____

 

7-      Does the person in respect of whom the compensation is claimed pay income tax, if so, state the amount of tax paid ? – 

 

____

8-      Place, date and time of accident – The accident took place on ____ at about ____ at ____ within the jurisdiction of ____

 

9-      Name & address of the police Station in whose jurisdiction The accident took place and the case Was registered – Police Station____ where the FIR No____ dated ____U/s. ____ IPC was got registered against the respondent No.1

 

 

10-  Was the person in respect of whom the compensation is claimed was traveling in the motor vehicle involved in the accident – ____

 

11-  Nature of injuries sustained – ____

 

 

12-  Name & address of the Medical Officer, if any, who attended the deceased – ____ 13-Period of treatment and expenditure – if any ? – ____

 

14-  Registration No. & type of the vehicle involved in the accident. – ____

 

15-  Name & address of owner of the offending vehicle – ____

 

16-Name & address of driver of offending vehicle. – ____

 

17-Name & address of the insurer of the offending vehicle. – ____

 

18-  Has any claim been lodged with the owner /insurer of the offending vehicle –  ____

19-  Name & address of the applicants – ____

 

20-  Relationship with the deceased – ____

 

21-Titlte to the property of the deceased – ____

 

22-Amount of compensation claimed – ____

 

23- Whether the claim petition is within time. – ____

 

24-Any other information that may be helpful in disposal of the claim petition –

 ____.............

 

25-Brief Description of the Accident:-  That on ____ at about ____ the deceased was going to ____ on his ____ and when he reached near ____ in a very slow and moderate speed on the left side of the road meanwhile the respondent No.1 driving the ____ rashly, negligently, carelessly without blowing any horn and in a high speed hit the ____ of the deceased from ____side while coming towards ____ side. Due to the hit the deceased fell down on the road sustained multiple grievous injuries on his ____ and body. The accident has been caused by the negligent and rash and careless driving by the respondent No.1.

 

PRAYER:-

 

It is therefore, prayed that the petition of the petitioners may kindly be accepted and an award of ____ /- (____ only) under section ____ of the ____ along with interest @ ___% p.a. from the date of accident till the date of realization of the amount in full may kindly be passed in favour of the petitioners and against the respondents jointly and severally with costs of the petition.

It is further prayer that an award of ____ /- under section____ of the ____ Act, under No Fault liability may also kindly be passed in favour of the petitioners and against the respondents jointly or severally.

                                                                                                                                                                          

                               PETITIONERS

 

Through counsel ____

 

Advocate, ____

 

VERIFICATION

Verified that the contents of our above petition from Para No.1 to 25 are true and correct to the best of our

knowledge and belief. The last Para is the prayer before this Hon’ble Tribunal Verified at ____ on __________

                                                                                                                                                                          

             PETITIONERS

 

 [CD1]Accident Death Claim Affidavit Format