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BEFORE THE HONOURABLE MOTOR ACCIDENTS CLAIMS

TRIBUNAL, MUVATTUPUZHA

O.P. (M.V) No. /2000

Petitioner

Vs
Respondents

1.
2.
3.
4.
5.
6.

APPLICATION FILED UNDER SECTION 166 OF THE MOTOR VEHICLES ACT;


1988 AND READ WITH RULE 371 OF THE KERALA MOTOR VEHICLES RULES,
1989.

I, * having been injured in a motor vehicle accident do hereby apply for the grant
of compensation for the injuries sustained.

Necessary particulars in respect of the injury, the vehicle etc. are given below.

1. Name and father's/ Husband's


name of the person injured

2. Full address of the person


injured

3. Age of the person injured

4. Occupation of person injured

5. Name and address of the


employer of the injured if any.

6. Monthly income of the person


injured

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 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 by the vehicle
involved in the accident. If so
give the names of the places of
starting of journey and
destination.

11. Nature of injuries sustained.

12. Name and address of the


Medical officers, if any who
attended on the injured

13. Period of treatment,


expenditure, if any incurred
thereon (to be supported by
documentary evidence)

14. Disability for work if any


caused.

15. Registration number and the


type of vehicle involved in the
accident.

16. Name and address of the owner


of the vehicle

17. Name and address of the insurer


of the vehicle

18. Name and address of the driver


of the vehicle at the relevant
point of time of the accident.

19. Has any claim been lodged with


the owner/Insurer if so with
what result?

20. Name and address of the


applicant.

21. Relationship of the injured

22. Title to the property of the


injured.

23. Amount of compensation


claimed

24. Particulars of loss and expenses

25. Other particulars if any which


the applicant wishes to give

PART I
Rs. Ps.
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)

26. Where the application is not made


within six months of occurrence of
the accident and cause thereof

27i) Whether the injured/ deceased has


been involved in any other road
accident earlier (in case he was
state details)

ii) Whether the injured/ deceased had


preferred a claim for damages in
any case earlier, and if so with
what result?

iii) Whether the injured/ deceased had


preferred claim from the owner of
the vehicle and if so how ?

28. Any other information that may be necessary or helpful in the disposal of the
claim.

I, Solemnly declare that the particulars given above are true and correct to the
best of my knowledge and belief.

Dated this the day of 200


Presented on

BEFORE THE HONOURABLE MOTOR


ACCIDENTS CLAIMS TRIBUNAL,
MUVATTUPUZHA

O.P. (M.V) No. /2000

Petitioner

Vs

Respondents

APPLICATION FILED UNDER SECTION


166 OF THE MOTOR VEHICLES ACT;
1988 AND READ WITH RULE 371 OF
THE KERALA MOTOR VEHICLES
RULES, 1989.

Valuation Rs.
Court fee Rs.

Advocate