Accident Death Claim Affidavit
1- ____ wife of ____ son of ____
2- ____ son of / daughter of ____ son of ____
All residents of _____ District ___ at present R/o _____.
VERSUS
1- ____ son of ____ resident of ____
(Driver of the offending vehicle ____ No. ____)
2- ____ son of ____ resident of ____
(Owner of the offending vehicle ____ No. ____)
3- _____ vide its Insurance Policy No. ____valid upto ____ issued from ____ branch office service may be effected through its Branch Manager at ____.
(Insurer of the offending vehicle ____ No. ____)
CLAIM PETITION UNDER SECTION ___ OF THE MOTOR VEHICLE ACT FOR GRANT OF COMPENSATION OF ____/- UNDER NO FAULT LIABLITY UNDER SECTION ___ OF ____
Sir
The petitioners most respectfully submit as under:-
We, the above-named petitioners being the legal heirs/representatives of deceased ____, do hereby apply for the grant of compensation, who died in the roadside vehicular accident caused by the respondent No.1 by driving the vehicle ____ rashly, negligently, carelessly, without observing the traffic rules, without observing the safety of the others at ____ within the jurisdiction of ____ on ____ at about ____.
The necessary particulars in respect of the vehicle, deceased etc. are given herein below:-
1- Name & father’s name of the person deceased - ____son of ____
2- Full address of the person deceased - ____R/o ____
3- Age of the person deceased - ____
4- Occupation of the person died - ____
5- Name and address of employer - ____
6- Monthly income of the person - ____
7- Does the person in respect of whom the compensation is claimed pay income tax, if so, state the amount of tax paid ? - ____
8- Place, date and time of accident - The accident took place on ____ at about ____ at ____ within the jurisdiction of ____.
9- Name & address of the police Station in whose jurisdiction The accident took place and the case Was registered - Police Station____ where the FIR No____ dated ____U/s. ____ IPC was got registered against the respondent No.1
10- Was the person in respect of whom the compensation is claimed was traveling in the motor vehicle involved in the accident - ____
11- Nature of injuries sustained - ____
12- Name & address of the Medical Officer, if any, who attended the deceased - ____
13-Period of treatment and expenditure - if any ? - ____
14- Registration No. & type of the vehicle involved in the accident. - ____
15- Name & address of owner of the offending vehicle - ____
16-Name & address of driver of offending vehicle. - ____
17-Name & address of the insurer of the offending vehicle. - ____
18- Has any claim been lodged with the owner /insurer of the offending vehicle - ____
19- Name & address of the applicants - ____
20- Relationship with the deceased - ____
21-Titlte to the property of the deceased - ____
22-Amount of compensation claimed - ____
23- Whether the claim petition is within time. - ____
24-Any other information that may be helpful in disposal of the claim petition - ____
25-Brief Description of the Accident:- That on ____ at about ____ the deceased was going to ____ on his ____ and when he reached near ____ in a very slow and moderate speed on the left side of the road meanwhile the respondent No.1 driving the ____ rashly, negligently, carelessly without blowing any horn and in a high speed hit the ____ of the deceased from ____ side while coming towards ____ side. Due to the hit the deceased fell down on the road sustained multiple grievous injuries on his ____ and body. The accident has been caused by the negligent and rash and careless driving by the respondent No.1.
PRAYER:-
It is therefore, prayed that the petition of the petitioners may kindly be accepted and an award of ____ /- (____ only) under section ____ of the ____ along with interest @ ___% p.a. from the date of accident till the date of realization of the amount in full may kindly be passed in favour of the petitioners and against the respondents jointly and severally with costs of the petition.
It is further prayer that an award of ____ /- under section____ of the ____ Act, under No Fault liability may also kindly be passed in favour of the petitioners and against the respondents jointly or severally.
Through counsel ____ Advocate, ____
VERIFICATION
Verified that the contents of our above petition from Para No.1 to 25 are true and correct to the best of our knowledge and belief. The last Para is the prayer before this Hon’ble Tribunal
Verified at ____ on __________
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