ANNEXURE-I FORM -I (Clause 20 (1)) FORM OF APPLICATON FOR COMPENSATION FROM SOLATIUM FUND I, ___________________________________Son of/daughter of /window of* Shri __________________________ residing at _________________________ having been grievously injured in motor vehicle accident hereby apply for grant of compensation for the grievous injuries sustained. Necessary particulars in respect of the injury sustained by m e are given below:- I, ___________________________________Son of/daughter of /Window of* Shri __________________________ residing at _________________________ hereby apply as legal representative/agent for the grant of compensation on account of death/injuries sustained by Shri/Shrimati/Kumari_________________ Son of /Widow of /daughter of Shri _________________________________ who had died/had sustained injuries in motor vehicle accident on ________________ at _________. Particulars in respect of accident and other information are given below: 1. Name and Father's name of Person injured (husband's name in case of Married women or widow) 2. Address of the person injured/dead 3. Age ____________ Date of Birth________ 4. Sex of the person injured/dead 5. Place, date and time of the accident. 6. Occupation of the person injured/dead 7. Nature of injuries sustained 8. Name and address of the police state in whose jurisdiction accident took place or was registered. 9. Name and address of the Medical Officer/Practitioner who attended on the injured/dead 10. Name and address of the claimant /claimants 11. Relationship with the deceased 12. Any other inform ation that may be considered necessary or helpful in the disposal of the claim I hereby swear and affirm that all the facts noted above are true to the best of my knowledge and belief. SIGNATURE OF THE CLAIMANT * Strike out whichever is not applicable. ANNEXURE-II FORM - II REGISTER OF DOCUMENTS REQUIRED FOR SOLATIUM SCHEME/ MACT CASES (TO BE MAINTAINED BY INCHARGE VICTIM ASSISTANCE CELL, SSP/UT OFFICE) List of Columns of the Register 1. S.No. 2. FIR No. 3. Police Station 4. Name of Address of deceased/injured 5. Name and Address of next of kin(where applicable) 6. Documents Received from Police Station 7. Diary of receipt of documents from Police Station. 8. Diary No. & Date of dispatch of documents to victim. 9. Remarks (Confirmation of receipt of documents,additional assistance required by victim etc.)
