7. Drafting of Accidental Claim
BEFORE THE MOTOR
ACCIDENT CLAIM TRIBUNAL ……
AT …….
Claim Appln. No. / YEAR.
Smt.
………… }
Age
- … Years, Occupation : Housewife }
R/at - …………………………, } Applicant
…………Pin
Code………………. }
V/S ...
1) …………………….. }
Age - ………..t, Occupation : ……..
}
R/at - ………………………………., }
Tal - ……….., Dist - ……….. State -…… }
Opponents
2) INSURANCE COMPANY
……………….,}
OFF. ADD. ………………….................. }
……………………………PIN CODE…… }
Claim : Rs.
………/-
( Rs.
………..Lac Only)
U/s 166 of M.V. Act
To
The
Member,
Motor
Accident Claim Tribunal,
…….
– Pin code ………………..
I, the above named
applicant, do hereby apply for grant of compensation for death …………. in a Motor
Vehicle Accident took place on date ……… at about ….. hours on ……………bi- Pass
Road, ……….., ……… within the limits of ………… Police Station, ……..
Necessary particulars in respect of
the Accident, Vehicle, Death etc. are given below ;
1. Full Name and Address of the : Shri ……………….. deceased
……………………………….,
…………………………Pincode
………….
2. Age of the deceased : …….
Years, Birth Date - ……………
3. Occupation of the deceased : ……………
4.
Name & Address of the : ……………………
employer of the deceased. ……………………….………,
…………………………..……
Pincode …………………….
5.
Yearly income of the : Rs. ……../- per month
deceased
6.
Place, Date and time of the : Place: ………………….
accident …………………………,
…………………………..
Date:
…………………...
Time: ……………………..
7. Was Person in respect of : Yes, the Deceased was riding
Whom compensation is Claimed,
Vehicle Name Moped bearing no.
traveling by the Vehicle involved
MH-………….(Vehicle No.).
in the accident if so, state the
place of the starting of journey
and its
destination.
8. Nature of injuries sustained in : Died on the spot.
the accident.
9.
Name & address of the
: …………….
Medical Officer / Practitioner,
if
Any, who attended on the
Deceased.
10.
Registration No. and type of
: Truck bearing no. …………..
vehicle involved in the accident.
11.
Relationship with the
: Applicant - …….
deceased
person of the
applicant
12. Title to
the property of the : Not Applicable.
deceased.
13. Amount of
compensation : Rs. ………../-
Clamed
14.
Any
other information that may be necessary or helpful in the disposal of in the claim application is as under :-
A.
The
applicants most respectfully submits that, at the time of accident deceased was
riding ……….Moped bearing no. MH-……… and
was proceeding towards his residence.
When decease came near the spot of accident at that time Truck bearing
no. ……….. came from back side and gave dash to the deceased and because of the
said dash deceased sustain severe injuries and died on the spot.
B.
The
applicant most respectfully submit that, the driver of the said Truck was
driving the said Truck in rash and negligent manner and in high and excessive
speed. It is the duty of the Truck
driver to drive the vehicle safely.
This applicant submits that, it is the duty of the Truck driver of the
Truck bearing no. …….. to take proper precautions to keep minimum distance from
the vehicle which was proceeding ahead of the said Truck.. However the Truck driver had not taken proper
care and precautions and because of high and excessive speed and because of
rash and negligent driving he could not control his vehicle and gave dash to
the deceased.
The applicant submits that, accident took place because
of rash and negligent driving on the part of Truck driver. It is further submitted that Driver of the
Truck was not observing the rules and regulation of the traffic laid down by
the Maharashtra Motor Vehicles Rules and also not following the mandatory
provisions of M.V. Act, 1988. The applicants submit that, the dash was so
severe that, the deceased sustained serious injuries. The applicants submit
that deceased died on the spot.
C.
After
the accident incident was reported to ….. Police station and investigating
officer of the …… Police station visited the spot of accident and drew the Spot
Panchanama and recorded the statements of the witnesses and come to the
conclusion that, accident took place because of the rash and negligent driving
on the part of Truck bearing no. …….. and char sheeted u/s 304-A, 279, 427 of
IPC and 119/177, 184 of M. V. Act.
D.
The
applicants most respectfully submits that the applicants has filled on record a
certified copy of the Spot Panchanama, FIR lodged by Police Havaldar of ………Police Station against the Truck Driver.
It is submitted that the contents of the Panchanama are self-explanatory
on the point of negligence on the part of Truck
Driver so also the contain of
F.I.R. also corroborating the contents of Panchanama on the point of
negligence on the part of Truck Driver. It is admitted that the fact of the accident is within the knowledge of the
Truck driver. All these circumstances, the principle of
Res Ipsa loquitur is clearly applicable to the present case.
The applicants submit that the deceased was aged …. years
and he was serving under the employment of ………. as a ……..(designation) and he
was getting salary of Rs. …../- per month.
The applicant most respectfully submits that, deceased was the only
earning member and the applicant are depending upon the Income of the
deceased. Applicant submits that,
decease was energetic and without any voices and he used to spent all the
income towards maintenance of the applicant.
The applicant most respectfully submits that, deceased was the only son
of the applicant.
E.
Considering
the income of the deceased the deceased would have achieve a great success in
the service. The applicant have suffered a severe shock and mental distress.
The applicant is under a great frustration and are now unable to recover from
this mishap. The applicant therefore submit that, considering the age of the
deceased the multiplier of 18 is applicable to present case.
F.
The
applicant submit that Truck bearing no. ………
was own by opponent no. 1. The
Truck bearing no. ……. was insured with
opponent no. 2 under policy no. ……….. for the period ………. to …………, hence the all the opponents are
liable to pay compensation to the applicant. This applicants says that all
these opponents are jointly and severally liable to pay compensation to the
applicants.
G.
The
accident took place within the jurisdiction of this Hon'ble Tribunal and
therefore Hon'ble Tribunal has got jurisdiction to try and entertain the
present application.
The Applicants therefore pray that,
a)
An
amount of Rs………./- be granted to the applicants by way of compensation from the
opponents.
b)
An
interest at the rate of 18% p.a. be granted to the applicants from the date of
filing this application till realisation of the amount.
c)
Cost
of this claim application be granted to the applicants from the opponent.
d)
Any
other just and equitable orders may please be passed in the interest of
justice.
Pune :
Date
:
Applicant
Advocate for applicants
V
E R I F I C A T I O N
I,
Smt. …………. the applicants herein do hereby state on solemn affirmation
that no claim in respect of the above mentioned accident has been
claimed by me or is pending before any other forum and that the contents of
this application is true and correct to the best of my knowledge, belief and
information ,and in witness whereof I have
signed this at Pune on the date mentioned above.
Applicant
BEFORE THE
MOTOR ACCIDENT CLAIM TRIBUNAL Place ….
AT PLACE …..
Claim Appln. No.
/ YEAR.
Smt.
……………………………………………………}
Age
- …..…Years, Occupation : Housewife
}
R/at - …………………………………, } Applicant
………………………………………… }
V/S ...
1) …………………….. }
Age - ………..t, Occupation : ……..
}
R/at - ………………………………., }
Tal - ……….., Dist - ……….. State -…… }
Opponents
2) INSURANCE COMPANY
……………….,}
OFF. ADD. ………………….................. }
……………………………PIN CODE…… }
Application
U/S 140 of M.V. Act
Amt. Rs. ……./-
The applicants
most respectfully submit as under :
1)
That
…………. died in the accident took place on (date) ……... Hence, the applicants are
applying for interim compensation u/s 140 of M. V. Act.
2)
It
is further submitted that, these applicant had filed application u/s 166 of M.
V. Act in which the details about the accident are given. To avoid repetition, the application u/s 166
may kindly be read at the time of hearing of this application.
3)
That
the applicants most respectfully submit that, the applicants had filed on
record F.I.R., Spot Panchnama, Death Certificate, Insurance policy along with
this application.
4)
It
is therefore necessary in the interest of justice that, an amount of Rs. …………./- u/s 140 of M.V. Act 1988 be awarded to the
applicants. If the same is not done then in that case the applicants will
suffer an irreparable loss and there will be miss carriage of justice. On the contrary, if the same is done, no
prejudice / harm will be caused to any of the Opponents.
The applicants
therefore pray that :-
a)
An
amount of Rs. ………./- U/S 140 of M. V.
Act will be awarded to the applicants from the opponents.
b)
An
Interest @ 18 % p. a. from the date of application till its realisation amount
will be awarded to the applicants from the opponents.
c)
Any
other order that the Hon'ble Tribunal may deem fit under the facts and
circumstances of the case kindly be passed.
Place :
Date :
Applicant
Advocate for applicant
V E R I F I C A T I O N
I, Smt. ………… the
applicants herein do hereby state on solemn
affirmation that no claim in
respect of the above mentioned accident has been claimed by me or is pending
before any other forum and that the contents of this application is true and
correct to the best of my knowledge, belief and information ,and in witness
whereof I have signed this at Pune on
the date mentioned above.
Applicant
BEFORE THE MOTOR ACCIDENT CLAIM TRIBUNAL Place ….
AT PLACE …..
Claim
Application No. of Year.
Smt.
…………… } Applicant
V/s
…………………………………… Company Ltd., } Opponents
and
others }
The application on behalf of the
applicant is as under ;
Applicant
have filed claim application for compensation on account of the death of ……………
in the a Motor Vehicle Accident took place on ……….. The applicant is not
aware of the procedures to be followed in
the Tribunal as well as the law of the land.
The applicant therefore
pray that, the applicant may kindly be allowed to appoint an advocate on their
behalf to conduct the case.
Pune
Date:
Applicant
BEFORE THE MOTOR ACCIDENT CLAIMS TRIBUNAL …….
AT ……..
Claim
Application No. of Year.
Smt.
…………… } Applicant
V/s
…………………………………… Company Ltd., } Opponents
and
others }
The
List Of Documents on behalf of Applicant is as follows -
1.
The
Certified True Copy Of F. I. R.
2.
The
Certified True Copy Of Panchanama
3.
The
Certified True Copy Of Inquest Panchanama.
4.
The
Certified True Copy Of Medical Notification of Death
5.
Xerox
copy of Insurance Policy.
6.
The
Certified True Copy Of Form COMP "AA"
7.
Xerox
copy of R. C. Book.
8.
Xerox
copy of National Permit.
9.
Xerox
copy of Certificate of Fitness.
10.
Xerox
copy of Driving License of Truck Driver
11.
Xerox
copy of Driving License of Decease.
12.
Salary
Certificate.
PLACE :
DATE :
ADVOCATE
FOR APPLICANT
BEFORE THE MOTOR ACCIDENT CLAIMS TRIBUNAL …….
AT ……..
Claim
Application No. of Year.
Smt.
…………… } Applicant
V/s
…………………………………… Company Ltd., } Opponents
and
others }
The address Purshish on
behalf of the applicant is as under ;
The addresses mentioned in
the claim application of the applicants and the opponents are true , correct
and with best of the knowledge of the applicants.
Hence this Purshish is
given.
Pune :
Dated :
Advocate for Applicants
BEFORE THE MOTOR ACCIDENT CLAIMS TRIBUNAL …….
AT ……..
Claim
Application No. of Year.
Smt.
…………… } Applicant
V/s
…………………………………… Company Ltd., } Opponents
and
others }
Application on behalf of
the applicant is as under ;
The applicant has filed
this claim application for the death of her son in the accident. It is now
required to issue notices to the opponents. The applicant has paid process for
RPAD notices to the opponents.
This applicants therefore
pray that , The notices be drawn to the opponents by RPAD & same be handed
over to the applicants.
Pune :
Dated :
Advocate for Applicants
