Motor Accident Compensation Claim Petition before MACT

BEFORE THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT ____________________

CLAIM PETITION NO. ______ OF 20__

IN THE MATTER OF:

Mr. / Ms. ________________________________
S/o / D/o / W/o ____________________________
Resident of ________________________________
CLAIMANT

VERSUS

1. Mr. / Ms. ________________________________
Address: ___________________________________
RESPONDENT NO. 1 - DRIVER

2. Mr. / Ms. / M/s _________________________
Address: ___________________________________
RESPONDENT NO. 2 - OWNER

3. __________________ Insurance Company Ltd.
Address: ___________________________________
RESPONDENT NO. 3 - INSURER

Police Station: ____________________

APPLICATION FOR COMPENSATION UNDER SECTION 166 OF THE MOTOR VEHICLES ACT, 1988 AND, WHERE APPLICABLE, RELIEF UNDER SECTION 164

Particulars of Claim

Facts of the Accident

1. That on ____________________ at about ________ AM / PM, the injured / deceased was ________________________________________________.

2. That the offending vehicle bearing registration No. ____________________, driven by Respondent No. 1 and owned by Respondent No. 2, was being driven in the following negligent / wrongful manner: ________________________________________________.

3. That due to the accident, the injured sustained the following injuries / the deceased suffered fatal injuries: ________________________________________________.

4. That FIR No. ______ dated __________ under the applicable penal provisions was registered at Police Station ____________________. The police papers / accident report are annexed where available.

5. That at the time of the accident the offending vehicle was insured with Respondent No. 3 under Policy No. ____________________, valid from __________ to __________, to the extent shown by the available policy record.

Grounds for Compensation

6. That the claimant is entitled to just compensation under Section 166 read with the other applicable provisions of the Motor Vehicles Act, 1988 on account of the death / bodily injury and consequential losses arising from the motor accident.

7. That the claimant has suffered pecuniary and non-pecuniary losses including ________________________________________________, for which compensation is claimed on the basis of the documents filed with this petition.

8. That, where Section 164 is invoked and legally applicable, the claimant seeks the fixed statutory no-fault compensation for death / grievous hurt without being required to plead or prove negligence for that statutory relief.

Jurisdiction

9. That this Hon'ble Tribunal has jurisdiction because ________________________________________________ [the accident occurred within its jurisdiction / the claimant resides or carries on business within its jurisdiction / the defendant resides within its jurisdiction].

Limitation

10. That the accident occurred on ____________________ and the present claim is filed within the period applicable under Section 166(3) of the Motor Vehicles Act, 1988. If any issue concerning limitation arises, the claimant relies upon the facts and law specifically stated in the accompanying application / pleadings.

Prayer

It is therefore respectfully prayed that this Hon'ble Tribunal may be pleased to:

(a) award just and reasonable compensation of Rs. ____________________ or such higher amount as may be determined in accordance with law;

(b) where applicable, grant compensation / relief permissible under Section 164 and the related statutory scheme;

(c) award interest under Section 171 or such interest as this Hon'ble Tribunal considers lawful and appropriate;

(d) direct the liable respondent or respondents to deposit and pay the awarded amount within the period fixed by this Hon'ble Tribunal; and

(e) pass any other order or relief considered just and proper in the facts and circumstances of the case.

Place: ____________________
Date: _____________________

CLAIMANT

Through Counsel, if represented
____________________, Advocate

Verification

I, ____________________, the claimant above named, verify that the factual statements made in paragraphs ______ to ______ are true to my knowledge and records, the legal submissions are based on advice received and believed to be correct, and no material fact has knowingly been concealed.

Verified at ____________________ on this ______ day of ____________________, 20__.

CLAIMANT

BEFORE THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT ____________________

CLAIM PETITION NO. ______ OF 20__

____________________    Claimant

VERSUS

____________________ & ORS.    Respondents

AFFIDAVIT

I, ____________________, aged about ______ years, S/o / D/o / W/o ____________________, resident of ________________________________________________, do hereby solemnly affirm and state:

1. That I am the claimant / authorised legal representative in the accompanying claim petition and am competent to swear this affidavit.

2. That the accompanying claim petition has been prepared under my instructions. The facts stated therein are true and correct to my knowledge and records, and the legal submissions are based on advice received and believed to be correct.

3. That the documents filed with the petition are true copies of their respective originals to the extent stated in the list of documents.

4. That I have disclosed any earlier claim, compensation, settlement or payment relating to the same accident to the extent known to me.

5. That no material fact relevant to the present claim has knowingly been concealed.

DEPONENT

Verification

Verified at ____________________ on this ______ day of ____________________, 20__, that the contents of this affidavit are true and correct to my knowledge and belief and nothing material has knowingly been concealed.

DEPONENT