Application For Claim in the Motor Accident Claims Tribunal

Updated at:March 2010
 
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IN THE COURT OF THE HON'BLE MEMBER,

MOTOR ACCIDENT CLIMS TRIBUNAL, ...

AT ......

Claim Application No........... /200...

  1. Smt. ..... )

    (Since deceased, legal heirs & guardian for )

    the minor applicant Nos. (ii) & (iii), )

    (i) Shri ....., " ) Applicants

    age ......., occupation - ........., )

    (ii) Kum. ....., )

    age .... years, occupation - student, )

    (iii) Master, )

    age ..... years, occupation - student, )

    (iv) Smt., )

    age ..... years, occupation -.., )

    All residents of ..........., )

    Vs

  2. Shri ......., )age - adult, occupation - ...... )resident of .........., )

    (Driver) ) Opponents

  3. M/s ......... ).........., )................ )

  4. The United India Insurance Company Limited, ).)

    CLAIM APPLICATION FOR COMPENSATION FOR Rs. .............../-

    The applicants abovenamed submit this application as the legal heirs of the deceased the Late Shri ........, who died in the motor accident, on, which took place on the .................. Road, near the ............, praying to state as follows:

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

  5. Name & Father's Name of the : person dead. :

  6. Full Address of the deceased :

    :

    : .

  7. Age of the deceased at the time : of accident. :

  8. Occupation of the deceased :

  9. Name & Address of the employer :

    : :

  10. Monthly Income of the deceased :

  11. Does the person in respect of : whom the compensation is :

    claimed pay income-tax? :

    - If so, give the details. :

  12. Place, Date & Time of the : accident. :

  13. Name & Address of the Police :

    Station in whose jurisdiction the :accident took place. :

  14. Was the person in respect of :

    whom the compensation is :

    claimed travelling by the vehicle :

    involved in the accident? :

  15. Nature of injuries sustained by :the deceased and the continuing :effect, if any. :

  16. Name & Address of the medical :officer who attended the deceased:

  17. Period of Treatment and :expenditure, if any, incurred :thereon (To be supported by :documentary evidence). :

    13 (a). Nature of injuries and whether:

    caused permanent disablement. :

  18. Registration No. & Type of the :vehicle involved in the accident. :

  19. Name & Address of the Owner :of the vehicle involved in the :accident. :

  20. Name & Address of the Insurance :Company of the vehicle involved :in the accident. :

  21. Has any claim been lodged with :the owner, insurer? If so, with :what result? :

  22. Name & Address of the :Applicants :

  23. Relationship of the applicants :with the deceased. :

  24. Title to the...

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