MODEL FORMAT OF MAIN CLAIM PETITION
UNDER SECTION 140 & 166 OF MV ACT
BEFORE THE MOTOR ACCIDENT CLAIMS
TRIBUNAL_________
MCOP NO. __________ OF 20__
IN THE MATTER OF:
Mr.
_________ CLAIMANT
VERSUS
1.
____________ RESPONDENT
NO.1
(OWNER)
2.
______________ Insurance Company Ltd RESPONDENT NO.2
(INSURANCE COMPANY)
APPLICATION UNDER SECTION 140 AND 166 OF MOTOR VEHICLES
ACT, 1988
1.
Address of the petitioner:-
-------------
Address for service of all processes and
notices for the petitioner is as stated above and that of his counsel
Mr.-------, Advocate, place.
2.
Address of the respondent:-
1.
---------
2.
----------
3.
I the petitioner above named do hereby apply
for granting compensation on account of the injuries sustained by me, in a
motor vehicle accident, which took place on ------ at about ---- hrs near
-----, on -------- main road in which a vehicle (type of vehicle) bearing
regn.no. ------------------- belonging to the 1st respondent,
insured with the 2nd respondent and a vehicle(type of vehicle)
bearing regn.no. -------------------- were involved. A criminal case was
registered in crime number ---/20—of ----- taluk police station under sec ---, ----- IPC.
Necessary particulars in respect of injured,
the vehicle etc. are given below:-
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1. |
Name and Father's Name of the Person injured |
_______________ s/o ______ |
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2. |
Full address of the Person injured |
------ |
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3. |
Age of the Person injured |
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4. |
Occupation of the Person injured |
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5. |
Name & Address of the Employer of the
injured |
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6. |
Monthly Income of the person injured |
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7. |
Does the person in respect of whom
compensation is claimed pay income tax? If so state the amount of income tax |
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8. |
Place, date and time of accident |
On ------ at about ----hrs near-----
on ----------main road. |
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9. |
Brief particulars of the accident |
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10. |
Name and address of the Police station in
whose jurisdiction accident took place or was registered |
-------- taluk police station crime
no. --/ 20—under sections----,----
IPC |
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11. |
Was the person in respect of whom
compensation is claimed traveling by the vehicle involved in the accident? If
so give the name and place of starting the journey and destination |
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12. |
Nature of Injuries sustained and
disablement, if any, caused |
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13. |
Name and address of the Medical Officer/
Practitioner, if any who attended the injuries |
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14. |
Period of treatment and expenditure if any
incurred |
The petitioner was immediately taken
to ----- hospital, and admitted as inpatient from ------ to -----. A sum of
Rs. ------/ was incurred towards medicines and medical charges. |
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15. |
Registration Number and type of vehicle
involved in the Accident |
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16. |
Name and Address of the owner of the vehicle |
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17. |
Name and address of Driver of the Offending
Vehicle |
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18. |
Name and address of the insurer of the
vehicle |
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19. |
Has any claim been lodged with the owner,
insure if so, by the Applicant with what result |
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20. |
Name and Address of the Applicant |
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21. |
Relationship with diseased |
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22. |
Title of the Property of the deceased |
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23. |
Amount of Compensation claimed and basis thereof Part – I a)
Loss of earnings for ---- months b)
Partial loss of earnings c)
Transport to hospital d)
Extra nourishment e)
Damages to articles f)
Others:- 1.
medical attendants 2.
medicines and medical charges 3.
compensation for shock and mental agony. Part – II g)
Compensation for pain and sufferings h)
Compensation for continuing permanent
disability i)
Compensation for loss of earning capacity. |
e.g. Pecuniary loss of earning, Medical
Expenses, Loss on account of Mental agony etc.. |
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24. |
Whether the application is not made within
six months of the occurrence of the accident, and the cause thereof. |
Deleted as per amended act 54/94. |
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25. |
Whether the injured has been involved in any
other road accident earlier (in case how and state details) |
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26. |
Whether the injured preferred a claim for
damages in any case earlier and If so with what result? |
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27. |
Whether the injured has preferred a claim
with the owner of the vehicle and if so, how? |
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28.
Any other information that may be necessary or helpful in the disposal of the
claim ( here furnish a brief account of how the accident occurred and state how
the applicant is entitled to claim compensation and how the respondents are
liable to pay compensation claimed.)
1.
On ------- at about ------ hrs, the petitioner was riding in his ------- (type
of vehicle) bearing regn.no. ----------------
from -------- to--------- near --------
on the left side of the ------------ main was incurred towards medicines
and medical charges to this petitioner. road. At that time a ------ (type of
vehicle)belonging to the 1st respondent, insured with the 2nd
respondent came from just behind without sounding horn in a high speed rashly, negligently
and hit at the petitioner vehicle, from behind. As a result of which, the
petitioner fell down on the road and sustained injuries and his vehicle also
heavily damaged. The petitioner sustained multiple injuries all over the body
besides fracture over ----, ------ . Immediately, after the occurrence, the
petitioner was taken to ---- hospital at ---- and admitted as inpatient from
---- to -----. Even after discharge, he is taking treatment till date
continuously as outpatient. A sum of more than Rs.---------/
2.
A criminal case u/s ----, ---- IPC has been registered by the ------ taluk
police station in crime number ---/20---, which is pending before the judicial
magistrate NO.-, -------- against the 1st respondent driver.
3.
The petitioner is aged about --- years, at the time of the accident and was
active. Due to the fracture over the left side chest, the petitioner is not
able to breath easily as before. Due to the fracture over the left leg big toe,
the petitioner is not able to stand for long time. Due to the injury, the
petitioner is permanently disabled. The petitioner was doing ------------- by profession and thereby
earned monthly a sum of Rs.------/ which has been now deprived off. The
petitioner is not able to continue his profession as before. Hence, he is
undergoing mental agony and physical sufferings. As the petitioner has become
disabled, his functional disability would be total and in future he would not be
able to do any work and the loss of income would be total.
4. The petitioner herein, due to the injuries
sustained in the accident, the petitioner has estimated a sum of Rs.------/
towards loss of earnings, he spent a sum of Rs.------/ towards transport to
hospital, Rs.-----/ towards extra nourishment, Rs.-----/ towards expenses on
person attending on him while under treatment and Rs.-----/ towards cost of medicines
and medical charges. However, a sum of Rs.-------/ has been claimed towards
compensation for pain and sufferings. The petitioner has claimed a sum of
Rs.----/ towards compensation for continuing permanent disability and that
for loss of earning power, he claims a
sum of Rs.----/. In total, the petitioner herein estimates the loss and
expenses at Rs.------/ However, he restricts his claim to the tune of Rs.----/
only since the petitioner herein the event of award of compensation by this hon’ble
tribunal, will get a lumpsum payment.
5. The 1st respondent is the owner of the vehicle (type
of vehicle) bearing regn.no.
-------------- . The 2nd respondent is the insurer of the said
vehicle. The accident taken place due to the rash and negligent driving of the
driver of the 1st respondent. Hence, respondents are jointly and
severally liable to pay compensation amount, as claimed by the petitioner
herein.
6. The petitioner has claimed a sum of Rs.-----------------/
towards compensation award amount and the court fees comes to Rs.------/ under
rule 24 (1) of MV claim rules. The petitioner has filed a separate application
for the grant of exemption from paying the court fees. Hence, a court fee of
rupee twenty is herewith affixed for the main claim petition.
7. The accident has taken place at -----
taluk p.s.limits, and the petitioner resides within the jurisdiction of the
motor accident claims tribunal (District judge) --------- . Hence, the claim
has been preferred by the petitioner before this hon’ble tribunal.
8. The petitioner has not preferred any
claim petition before any other forum for the grant of compensation in respect
of this accident.
It is therefore prayed that this hon’ble
court may be pleased to pass an order:-
a)
Directing the respondents 1 and 2 to pay the
petitioner a sum of Rs.--------/ towards compensation with future interest at
12% p.a from the date of petition till payment.
b)
Directing the respondents 1 and 2 to pay the
cost of this petition; and
c)
Granting such other relief as this hon’ble
court may deem fit and proper in the circumstances of the above case and thus
render justice.
Sd xx
sd xx
Advocate for the petitioner
Petitioner
I, the petitioner herein do hereby declare
that the facts stated above are true to my knowledge and that I sign this on
---th day of -----, 20—at ------------- .
Sd xx
Petitioner.
List
of documents:-
1.
Xerox copy of the F.I.R.
2.
Xerox copy
of the case sheet
3.
Xerox copy
of the insurance policy
4.
Xerox copy of the Aadhaar card of the
petitioner
Advocate.
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