Before the Motor Accidents Claims Tribunal (District
Judge)
place
M.C.O.P.N.O
/ 2022.
-------
Petitioners
VS
----- Respondents.
APPLICATION UNDER SECTION 166 OF THE MOTOR VEHICLES
ACT 54/94 AND FORM –II, SEE RULE 4 (1) AND (2) OF THE TAMILNADU MOTOR VEHICLE
ACCIDENTS CLAIMS TRIBUNAL RULES, 1989 AND MADE THEREUNDER IN G.O.Ms.1170 HOME
(TRANSPORT – VII) DATED 1.7.1989.
1. Address of the petitioner
-------
The
address of service of all process and notices for the petitioners is as stated
above and that of their counsel
M.S. No. cell NO. Advocate, Number .
2. Address of the
Respondents.
-------
3. We, the petitioners above named do hereby apply for
granting compensation on account of the death of one in a motor vehicle accident, which took
place on at about PM near
in which a bearing
regn.no. belonging to the 1st
respondent insured with the second respondent was involved. A criminal case was
registered in crime number / of
police station under section 304 - A
IPC.
4. Necessary particulars in respect of the deceased, the
vehicle etc., are given below:
1. Name and Father’s name :
Of the person dead (Husband’s
Name in the case of married
woman and widow)
2. Full address of the person :
Dead.
3. Age of the person dead :
4. Occupation of the person dead :
5. Name and address of the
Employer of deceased
if any :
6. Monthly income of the person :
Dead.
7. Does the person in respect of :
Whom compensation is
claimed
Pay income tax? If
so state the
Amount of income tax
(to be
Supported by
documentary
Evidence)
8. Place, date and time of the :
Accident.
9. Name and address of the police : station in whose
jurisdiction the
accident took
place or was
registered.
10.Was the
person in :
respect of
Whom compensation
is claimed
Travelling in by the
vehicle
Involved in the accident?
If So give the
names of places
Of starting
of journey and
Destination.
11.Nature of injuries
sustained :
By the deceased.
12.Details of damages
caused :
To the property on
account
of the accident.
13. Period of treatment
and :
Expenditure if any,
incurred
There on (to be
supported by
Documentary evidence)
14. Registration number
and :
The type of the
vehicle
Involved in the
accident.
15. Name and address of
the :
Owner of the vehicle
16. Name and address of
the :
Insurer of the vehicle
16.(a) Name and address of
the :
Driver-in-charge of
the
Vehicle at the time
of accident.
17. Has any claim
been lodged :
With the owner/insurer?
If so with what result?
18. Name and
address of the :
Petitioners.
19. Relationship
with the :
Deceased.
20. Title to the
property of the :
Deceased.
21. amount of
compensation :
Claimed.
21. (a)
Particulars of loss and
Expenses:
PART – I
a.
loss of earnings :
Rs.
Rs. X 12 x
b.
loss of future
prospects : Rs.
c.
Transport to hospital
& : Rs.1,00,000/
Funeral expenses.
d.
Extra nourishment :
Rs.
e.
Others:
1.
Compensation for loss
of :
Rs.
Consortium.
2.
Compensation for loss
of :
Rs.2,00,000/
Love and affection
3.
Compensation for
shock : Rs.2,00,000/
And mental agony
caused
To the petitioners
4.
Compensation for
loss : Rs.2,00,000/
Of service.
5.
Compensation for loss
of :
Rs.2,00,000/
Guidance
PART
– II
6.
Compensation for pain
and :
Sufferings.
7.
Compensation for
continuing :
Permanent
disability
8.
Compensation for loss
of :
Earning power.
Total : Rs.
Claim restricted to Rs.
22. Whether the application is
:
Not made within six months
Of the occurrence of the
Accident, and the cause
thereof
a. Whether the deceased has been :
Involved in any other road
Accident earlier (in case how and
State details)
b. Whether the deceased has :
Preferred a claim for damages
In any case earlier and if so
With what result?
c. Whether the deceased has :
Preferred a claim with the owner
Of the vehicle and if so, how?
23. 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 the compensation claimed)
1. On at
about the deceased was , at that
time a bearing regn.no. belonging to the 1st respondent, insured
with the 2nd respondent driven by its driver in a high speed,
rashly, negligently and hit against the
As a result of which the deceased sustained serious injuries and then
succumbed to the injuries.
2. A case under section 304-A IPC has been registered
by the police station in crime
number / against the first respondent driver which is
now pending before the judicial magistrate court at .
3. The deceased was doing work and thereby earning a sum of Rs. / pm. The deceased used to spend her entire
earnings only to the welfare of the petitioners. The petitioners lost their
beloved mother. The petitioner’s family not only lost the dearest but also
suffering heavy financial loss. If at all the deceased did not met with this
tragic accident she would have lived upto her 90 years and earned name and fame
to the family. Though the deceased was aged
years at the time of accident, she was hale and healthy. The petitioners
are very much affectionate towards the deceased. Now there is nobody to give
financial help and kindness towards the petitioners.
4. The petitioners have spent a sum of Rs.50,000/
towards funeral expenses. The petitioners have estimated a sum of Rs.2,00,000-
towards compensation for the loss of love and affection. The petitioners
estimates a sum of Rs.2,00,000/ towards compensation for mental agony and
mental shock. The petitioners have estimated a sum of Rs.2,00,000/ for the loss
of service. The petitioners have also estimated a sum of Rs.2,00,000/ for the
loss of guidance. The petitioners are estimating a sum of Rs. / towards compensation for the loss of
earning In total the petitioner estimate
their loss and expenses on account of the deceased and death of the deceased at
Rs. / Even then the petitioners
restrict their claim to a sum of Rs. /
since they will get lumpsum amount in
the event of award of compensation by this hon’ble tribunal
5. The 1st respondent is the owner of the
tractor bearing regn.no. which was
involved in the accident. The 2nd respondent is the insurer of the
said vehicle. The 3rd respondent is the divisional office of the2nd
respondent. The accident had occurred only due to rash and negligent driving of
the driver of the 1st respondent. Hence the respondents are jointly
and severally liable to pay compensation as claimed by the petitioners herein.
6. The petitioners have claimed a sum of R. /(Rs.
Only) towards compensation award amount and the court fees comes to
Rs. Under rule 24(1) of MV claim
rules. The petitioners have filed a separate application for the grant of
exemption from paying the court fees of Rs.
/. Hence a nominal court fee of Rs.372.50 is paid in the main claim
petition.
7. The insurer, the 2nd respondent office,
policy issuing office is at . But the 3rd respondent,
divisional office of 2nd respondent is situated at , within the jurisdiction of the motor
accidents claims tribunal (District judge)
. Hence the claim has been preferred by the petitioners before this
hon’ble tribunal.
8. The petitioners have 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
to pay the petitioners a sum of Rs. /
(Rs. Ony) towards the compensation
with future interest at 12% p.a. from the date of petition till payment;
b.
Directing the respondents
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.
Advocate for the petitioners Petitioners
We, the petitioners herein do hereby declare that the
facts stated above are trueto our knowledge and belief and we sign this on
the day of 20
at .
Petitioners
LIST OF DOCUMENTS:
1.
Xerox copy of the first
information report.
2.
Xerox copy of the
insurance policy.
3.
Xerox copy of the
postmortem certificate.
4.
Xerox copy of the Aadhaar
card of the petitioners ( numbers)
Advocate.
r
BEFORE THE MOTOR
ACCIDENTS
CLAIMS
TRIBUNAL (DISTRICT JUDGE)
PLACE
MCOP / 21
==========================
Application under section 166 of
the motor
vehicles amended Act
54/94 of the Tamilnadu motor
Vehicles Accidents claims
Tribunal rules 1989 and made
There unde G.O.Ms.No.1170
Home (Transport VII dated
1.7.1989)
=========================
& others
--- Petitioners
By Advocate
MS.NO. /
Cell NO
And others
--- Respondents
Enclosures:
Vakalath
Batta memo
Documents
Affidavits
Petition & Affidavit
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Total
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