Claim Petition Affidavit
Claim Petition under Section ______ of _________ for grant of Compensation of Rupees _________/-
Respectfully showeth: -
1. The above mentioned petitioner do hereby apply for grant of compensation on account of injuries sustained by the petitioner in accident caused by respondent no. 1, which took place on __________- at about _________. near ____________________, within the area of Police Station – _________ due to rash & negligent driving of ________________, who hit the petitioner from his back, resultant sustained multiple injuries including grievous on his person.
The necessary particulars in respect of the injured and vehicle etc. are given below: -
1- Name & Father’s Name _______________
of the person injured
2- Full address of the _________________
person injured. __________
3- Age of the person __________
4- Occupation of the person ______________
5- Name & Address of the ___________________
employer of the person
6- Monthly income of the person About _____________ Per Month
7- Does the person in respect of _______________
whom compensation is claimed
pay income tax, if so, state the
amount of tax.
8- Place, date and time of On ___________ at about _________
accident. In front of ________________
9- Name and address of the police ______________________
Station in whose jurisdiction,
the accident took place or was
10- Was the person in respect of ______________-
whom compensation is claimed
traveling in offending vehicle
If so state the starting of his
Journey & destination
11- Nature of injuries ______________________
12- Name & address of the _________________
medical Officer who
attended the injured
13- Period of treatment and _____________________
expenditure, if any,
14- Registration no. & type of _____________________
vehicle involved in
15- Name & address of the owner _______________________
16- Has any claim been lodged ______________________
with owner insurer
17- Relationship with injured ___________________________
18- Name & Address of the __________________
19- Amount of Compensation. Rupees ____________/- Under Section
claimed _________________ Act.
20- Any other information that may be helpful necessary in disposal of claim petition
(I) That the petitioner- injured was coming with_____________ at about _____________ on _____________ and when reached ________________ then ______________________ driven by respondent no. 1 negligently, carelessly without obeying the traffic rules, without blowing horn without Appling over the brakes of the vehicle in question, directly hit the petitioner from behind, in result the petitioner fell. The accident was seen by ____________, who ______________ and was brought, in ___________ Hospital.
(II) That the statement of the petitioner was recorded in _____________ by the police and a criminal case vide F.I.R. no. _____________ I.P.C. was Registered on ______________ on the statement of petitioner in respect of the accident taken place as stated above.
(III) That the petitioner is a man/women of approximately______ years of age, prior to this accident was running _____________ and earning more than Rupees ________/- per month and impressed every one who came into his hospitality and after the accident has become unemployee, confined to the bed and in future unable to walk and to do any hard work, even to run his business like previously but has come in a debt due to spending a huge amount over the treatment i.e. medicine, traveling, nursing aids etc., even have become unfit from his mind, unable to understand any thing properly and fully dependent over other family members, the life of the petitioner has sunk in a pool, in black dark as a life fully handicapped as beggar.
(IV) That the accident was caused due to reckless, careless, negligent, without obeying the traffic rules and without applying over the brakes of ________________________ in result the petitioner sustained grievous multiple injuries on his person.
(V) That the respondents are liable to pay compensation to the petitioner jointly and severally, being owner, driver, insurer of vehicle in question.
(VI) The accident taken place, the petitioner and respondent no. 1 is residing, cause of action accrued with in territorial jurisdiction of this tribunal, hence this tribunal has got jurisdiction to register, try, entertain and decide the instant petition.
(VII) That no other petition is pending or decided between the same parties regarding the same subject matter.
(VIII) That a proper court fee as per law has been affixed.
It is therefore most respectfully prayed that the petition of the petitioner may kindly be accepted with cost and awarded for Rupees _______________/- under section _________________ Act with interest @ 18% per annum form the date of accident till payment, may kindly be passed in favour of the petitioner and against the respondents jointly and severally.
Or any other relief, which this Hon’ble tribunal deems fit and proper in the eyes of law, circumstances of petition on adducing evidence also be passed in favour of the petitioner and in the interest of justice.
Through Counsels: -
Verified that each and every contents and averments mentioned hereinabove have been read over and explained to me by my engaged counsels in Hindi, same are true and correct to the best of my knowledge and belief and nothing has been concealed therein.
Verified at _________________ on _______________