MOTOR VEHICLE COMPENSATION
IN THE COURT OF MOTOR ACCIDENT CLAIMS TRIBUNAL AT COIMBATORE
MAC No:_______ of 2008
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 _______
- Damages _______
- 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.
Coimbatore
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 Coimbatore this the -- day of ._______
Petitioner
IN THE COURT OF MOTOR ACCIDENTS CLAIMS TRIBUNAL AT COIMBATORE
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. _____ 50,000/- 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. _____ 50,000/- 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. _____ 50,000/- 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.
Coimbatore
Petitioner
______
Through, Advocate
IN THE COURT OF MOTOR ACCIDENTS CLAIMS TRIBUNAL AT COIMBATORE
MAC No.: ______ of 2008
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 Coimbatore 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 Coimbatore
______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 2001 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 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 Coimbatore
______ Versus ______
Suit : Claim Petition Date of hearing:
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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 : ______
