In the Court of the Motor Accident Claims Tribunal, Chandigarh Claim Petition No. ______________________ ______________________________ ______________________________ ______________________________ ______________________________ ... Petitioner VERSUS ______________________________ ______________________________ ______________________________ ______________________________ ... Respondent Application under the Section 166 & 140 of the Motor Vehicle Act 1988 for grant of Compensation Sir, 1. Name & Father's Name of the person injured/dead (Husband's 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 Chandigarh on this the________day of_________200______that the contents of the above application are true and correct to my knowledge and belief. Petitioner Following documents should accompany the petition: - 1. Copy of the FIR registered in connection with said accident, if any. 2. Copy of the MLC/Post Mortem Report/Death Report as the case may be. 3. The documents of the identity of the claimants and of the deceased in a death case. 4. Original bills of expenses incurred on the treatment along with treatment record. 5. Documents of the educational qualifications of the deceased, if any. 6. Disability Certificate, if already obtained, in an injury case. 7. The proof of income of the deceased/injured. 8. Documents about the age of the victim. 9. The cover note of the third party insurance policy, if any. 10. An affidavit in support of the above documents and detailing the relationship of the claimants with the deceased.
