MOTOR VEHICLE COMPENSATION [CD1]
IN
THE COURT OF MOTOR ACCIDENT CLAIMS TRIBUNAL AT ……………………
MAC No:_____________ of 20………….…..
…………………………………………………………………………………..Petitioner
Versus
…………………………………………………………………………………..Respondents
Petition
Under Section 166 of the Motor Vehicles Act for the Grant of Compensation to
the Petitioner on Account of Damage to his _________
Respectfully
Sheweth:
I, The above named
petitioner, do hereby apply for the grant of compensation loss/damage sustained
to my property described as _____ by use of Motor Vehicle of the respondent No.
______. The necessary particulars of the _____ in question are given as under:-
1.
Name and father's name of the
claimant: Same as given in memo of parties above.
2.
Full address of the property:
Resident of : _______
3.
Age of the injured: _______
Years.
4.
Occupation of the injured:
_______ presently
5.
Name and address of the deceased/injured
: Resident: _______
6.
Did the person in whose respect
compensation is claimed pay income tax : ______-_Yes/No
7.
Monthly income :Rs.
_______
8.
Place, date and time of
accident : Accident took place at _______
9.
Name of police station : PS :
_______
10.
Was the person in whose respect
the compensation is claimed traveling in the bus and if so than the place of
start of journey & destination: The person in whose respect the
compensation is being claimed was traveling in the _______
11.
Nature of the loss/injury sustained by
the property: The
_______
12.
Name and address of the person who attended/visited
the property: _______
13.
Period of treatment and
expenditure: The injured/deceased remained under treatment from _______
14.
Registration and type
of vehicle
involved in
the accident:
Regn No.
_______
15.
Name of the insurer: Not known.
_______
16.
Has any claim been lodged with
the insurer : _________Not known.
17.
Name and address of the owner
of the vehicles: Same as given in memo of parties above.
18.
Name and address of the applicant:
Same as given in memo
of parties
above.
19.
Relation with the
deceased/injured : The petitioner _______
20.
Title to the property : The
_______
21.
Amount of compensation: -
Injury _______ - Love & Affection _______ - Medical Expenses _______
Images _______ - Pain & mental Agonies
_______ - Loss of Marital Bliss _______ Total ______________
22.
Any other information which may
be necessary for the disposal of the claim: The ________
23.
Reasons or grounds for late
submission of claim application on which condonation of delay is claimed. The
claim application is within the period of limitation.
24.
Cause of Accident with brief
description : The accident took place due to rash and negligent driving of the
driver of the vehicle. __ It is, therefore, respectfully prayed that the
petition may kindly be allowed and the petitioner may kindly be awarded
compensation amounting to Rs. _________ as ________ and interest thereon @18%
per annum till payment against all the respondents jointly and severally.
…………………………………..
Petitioner
______________
Through,
Advocate Verification:
I, the above named
deponent do hereby verify that the contents of this affidavit of mine are true
and correct to the best of my knowledge and belief.
Verified at
……………….. this the -- day of ._______ Petitioner
IN THE COURT OF
MOTOR ACCIDENTS CLAIMS TRIBUNAL AT …………………………
………………………………………………………………Petitioner
Versus
……………………………………………………….……Respondents
Application Under Section 140 of The Motor
Vehicles Act For Compensation On Account Of No Fault
Liability
Respectfully
Sheweth :
1.
That the petitioner hereinabove
has filed an application under the Motor Vehicle Act in this Hon'ble Court,
hearing/final disposal whereof will take some time.
2.
That it is apparent from
perusal of grounds and documents attached therewith that the petitioner has
prima facie a very good case in his favour and the petition is bound to
succeed.
3.
That the balance of convenience
is clearly in favour of making of an interim order granting a sum of Rs.
……………………..- on account of No Fault Liability to the petitioner pending disposal
of the petition.
4.
That interest of justice
demands that the respondents are directed to deposit and pay a sum of Rs.
…………………………- to the petitioner as admittedly the ______________death/permanent
disablement has been occasioned by the use of the vehicle of the respondents
and the same is amply evident from the perusal of grounds of petition and the
documents attached therewith.
5.
It is, therefore, most humbly
prayed that this application may kindly be allowed and the respondents be
directed to deposit and pay a sum of Rs. ………………..… to the petitioner under the
Act on account of No Fault Liability in interest of justice.
FOR THIS ACT OF KINDNESS, THE HUMBLE
APPLICANT AS IN DUTY BOUND, SHALL EVER PRAY.
……………………….
Petitioner
______
Through,
Advocate
IN THE COURT OF MOTOR ACCIDENTS CLAIMS TRIBUNAL
AT …………………………
MAC No.: ______ of 20……..
…………………………………………………………………..Petitioner
Versus
………………………………………………………..Respondents
Affidavit in
support of Application under Section 140 of the Motor Vehicles Act
I,_____________,
do hereby solemnly affirm and declare as under :-
1.
That the accompanying
application has been prepared under
my instructions.
2.
That the contents of paras 1 to
5 of the accompanying application are correct and true to the best of my
knowledge.
3.
That I further solemnly affirm
and declare that this affidavit of mine is correct and true, no part of it is
false and nothing material has been concealed therein.
Affirmed at …………………………….. this the ______.
Deponent
In the above noted
suit every summons, notice & other order may be served on me on the address
given above during the pendency of the suit. Change of Address will be
intimated to the Court.
Dated :
______
Plaintiff/Petitioner
Defendant/Respdt
Through,
Advocate
PROCESS FEE
In the
Court of : Motor Accidents Claims Tribunal
at…………………..
…………………………………………………………………………….
Versus
……………………………………………………………………………..
Claim : Accident
Claim______
Petitioner For
the service of respondents:-
Advocate
Received on
__________________ Court-fee stamp of the value of Rs. ______________ with
___________ ____ copies in
case No. __ of 20………
………………………………………………………………………….
Vs
………………………………………………………………………
Signature of the
Head Notice Writer
Under Order 7
Rule 13 (1) CPC
List of
documents filed by Plaintiff
In the Court of
: Motor Accidents Claims Tribunal at Coimbatore
…………………………………………………………………………….
Versus
………………………………………………………………………………..
Date Of Hearing:
______
Suit for : Claim
Date of
Production :______
S.No Details, Date What is If documents If
Rejected Documents Intended Filed what is then the to be the
Exh marked date of
Proved from on it return
of Documents
To prove
petitioner's case
1. FIR
2. Postmortem Report ______
3. School Leaving Certificate ______
4. Income Certificate ______
Date: ______
Counsel for Plaintiff/Defendant
List of Document
Relied Upon
Under Order 7
Rule 14 CPC Filed by : ______
In the Court of : Motor Accidents Claims Tribunal
at………………………………
…………………………………………………………………..
Versus
……………………………………………………………..
Suit : Claim Petition Date of
hearing:
----------------------------------------------------------------
1.
Have you produced any Yes Sir,
as per list. documents with the plaint so, what are those document.
2.
Do you wish to produce any more
Yes sir, if required. documents which are in your possession and custody if so,
what are those documents.
3.
Do wish to relay upon any Yes
sir, later on from other documents, if so in various authorities.
whose possession they are and what are
those documents.
-----------------------------------------------------------
Counsel for
Dated : ______
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