FORMAT OF APPLICATION FOR COMPENSATION IN MOTOR ACCIDENT
In the Court of the Motor Accident Claims Tribunal .(Name of Place) Claim Petition No. _______ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Petitioner VERSUS _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Respondent Application under the Section 166 & 140 of the Motor Vehicle Act 1988 for grant of Compensation 1. Name & Fathers Name of the person injured/dead (Husbands Name in case of married women & widow) : 2. Full address of the person injured/dead : 3. Age of the person injured/dead. : 4. Occupation of the person injured/dead : 5. Name & address of the employer of the injured / dead. : 6. Monthly income of the person injured/ dead. : 7. Does the person in respect of whom compensation is claimed pay income tax? If so state the amount of the income tax (to be supported by document) : 8. Place, date and time of accident : 9. Name & Address of Police Station in whose jurisdiction the accident took place & FIR was registered. : 10. Was the person in respect of whom compensation is claimed traveling by the vehicle involved in the accident ? If so, give the name & place of starting the journey and destination. : 11. Nature of the injuries sustained. : 12. Name & Address of the Medical Officer/Practitioner, if any who attended to the injuries. : 13. Period of treatment and expenditure. : 14. Registration No. & Type of vehicle involved in accident. : 15. Name & address of the owner of offending vehicle. : 16. Name & address of the driver of offending vehicle. : 17. Name & address of the insurer of the vehicle. : 18. Has any claim been lodged with the owner/insurer, if so, with what Result : 19. Name & address of the applicant. : 20. Relationship with the deceased / injured. : 21. Title of the property of the deceased/injured. : 22. Amount of compensation claimed. : 23. Any other information that may be necessary and helpful in the disposal of the case. : 24. Prayer : Petitioner Verification: Verified at Delhi on this the ________ day of _________ 200__ that the contents of the above application are true and correct to my knowledge and belief
