IN THE COURT OF MOTOR ACCIDENT CLAIMS TRIBUNAL AT _______________
MAC No: ____________
______________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 :
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:
2. Same as given in memo of parties above.
3. Full address of the property:
4. Resident of : _______
5. Age of the injured:
6. _______ Years.
7. Occupation of the injured:
8. _______ presently
9. Name and address of the deceased/injured :
10 Resident: _______
11. 6. Did the person in whose respect compensation is claimed pay income tax :
12. ______-_Yes/No
13. Monthly income :
14. Rs. _______
15. 8. Place, date and time of accident :
16. Accident took place at _______
17. 9. Name of police station :
18. PS : _______
19. 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:
20. The person in whose respect the compensation is being claimed was traveling in the _______
21. 11. Nature of the loss/injury sustained by the property:
22. The _______
23. Name and address of the person who attended/visited the property: _______
24. Period of treatment and expenditure :
25. The injured/deceased remained under treatment from _______
26. 14. Registration and type of vehicle involved in the accident :
27. Regn No. _______
28. 15. Name of the insurer :
29. Not known. _______
30. 16. Has any claim been lodged with the insurer :
31. _________Not known.
32. Name and address of the owner of the vehicles:
i. Same as given in memo of parties above.
33. Name and address of the applicant:
34. Same as given in memo of parties above.
35. Relation with the deceased/injured :
36. The petitioner _______
37. Title to the property :
38. The _______
39. 21. Amount of compensation:
40. - Injury _______
41. - Love & Affection _______
42. - Medical Expenses _______
43. - Damages _______
44. - Pain & mental Agonies _______
45. - Loss of Marital Bliss _______
46. Total ______________
47. Any other information which may be necessary for the disposal of the claim:
48. The _____________________
49. Reasons or grounds for late submission of claim application on which condonation of delay is claimed.
50. The claim application is within the period of limitation.
51. 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.
(Name of Place) 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 (Name of Place) 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 :
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.
(Name of Place) Petitioner
______ Through, Advocate
IN THE COURT OF MOTOR ACCIDENTS CLAIMS TRIBUNAL AT ________________
MAC No.: __________
__________________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 (Name of Place) this the ______.
Deponent
In the Court of : Motor Accidents Claims Tribunal at ______________(Name of Place)
______ Versus ______
SUIT : Accident Claim
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Name & Parentage |
Address |
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1.
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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 (Name of Place)
______Versus ______
Claim: Accident Claim
Date of Hearing: ______
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Date |
By Whom Filed |
Purpose |
Amount |
Stamp |
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Petitioner For the service of respondents:-
Advocate
Received on ______ Court-fee stamp of the value of Rs. ____ with ____ copies in case No. __ of 2003 in Re. ______ 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 __________________
______ 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 ___________________________
Document 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 : ______
