Form ‘G’
(See Rule 8 and 20)
Application for grant of compensation under the Motor Vehicles Act, 1988
BEFORE MOTOR ACCIDENT CLAIMS TRIBUNAL , DELHI
- SURAJ S/O SH. X
R/O. PRESENT ADDRESS-
4 , School Block, Shakarpur, Delhi-92
PERMANENT ADDRESS-
House no. X, P.S. Gorakh Nath,
Gorakhpur, U.P.
VERSUS
- Guddu Kumar S/o Sh. XX,
R/o H.No. Y, Village Z, …. Driver
- Todar Mal S/o. XX,
R/o. H.No. X, Okhala , New Delhi ….. Owner
- The Insurance Company. Ltd.
Off: 12XX, 20th Floor,
Kasturba Gandhi Marg, New Delhi-1 …… Inssurance.
RESPONDENTS
The undersigned makes this application for grant of compensation as per the provisions of the Motor Vehicles Act, 1988 on the basis of the following facts and information:-
PART-I
Sir,
- Name & Father’s Name of the person : Suraj , S/o XX,
injured/dead (Husband’s Name in the
case of married woman & widow)
- Full address of the person injured/ : As above mentioned.
dead.
- Age of the person injured/dead : 25 Years
- Occupation of the person injured/ : Private job as Account Assistant.
dead.
- Name & address of the employer of : M/s. Hoteliers
the injured/dead Pvt. Ltd., Off. Building No.X,
, New Delhi
- Monthly income of the person injured/ : 16,000/- Per Month.
dead.
- Does the person in respect of whom : No
compensation is claimed pay income
tax? If so state the amount of the income
tax (to be supported by documents).
- Place, date and time of accident. : P R Road, Auranzeb Lane cut,
New Delhi on Dt. 28.03.2022 at
About 9 P.M.
- Brif particulars of the accident : That the petitioner/ injured was
going By his motor cycle No. HR 99 NK XXXX from Vasant Kunj to Laxmi Nagar, Delhi , therefore during that process when he reached at Prithvi Raj Road, Aurenzeb Cut , a Maruti car bearing No. DL 1LS XXX hit the petitioner in excessive speed.
- Name & address of Police Station : S. Tughlak Road, FIR No.29/22
in whose jurisdiction the accident U/s.379/337 IPC,
took place or was registered.
- Was the person in respect of whom : The petitioner was going by his
compensation is claimed traveling by Motor Cycle No. HR 99 NK XXX
The vehicle involved in the accident? If from Vasant Kunj to Laxmi
so, give the Name & place of starting the Nagar, Delhi
journey and destination.
- Nature of the injuries sustained and : Grievous Hurt, Bone Fracture in
disablement, if any, caused right shoulder along with sever
Injuries and pain.
- Name & Adress of the Medical : Doctors of RML Hospital,
Officer/ Practitioner if any who New Delhi
attended on the injuries.
- Period of treatment and expenditure : 10,000 spent on treatment
if any incurred and treatment is still continue.
- Registration No. and type of vehicle : DL 1LS XXXX, Maruti Car
involved in the accident
- Name and address of owner of the : Respondent No. 2
Vehicle.
- Name and address of driver of the : Respondent No. 1
Vehicle.
- Name and address of Insurer of the : Respondent No. 3
Vehicle.
- Has any claim been lodged with the : – A. –
owner/ insurer, if so, with what result.
- Name and address of the applicant. : As per title of the claim petition
- Relationship with the deceased/injured : – Self –
- Title of the property of the deceased/injured : – A. –
- Amount of compensation claimed & : Rs. 5,00,000 ( Rupees five
basis thereof. Lakhs only)
- Whether reports from the police and
The Registering Authority have been : – Yes –
obtained in Form ‘A’ & ‘D’ ( if so to be
annexed).
- Whether affidavit of the applicant and – Yes –
witnesses as per rule 8 are annexed
(give details)
- Whether documents mentioned in rule 8 : – Yes –
are being annexed duly indexed
( give details)
- Any other information that may be
necessary and helpful in the disposal
of the case.
- That on 28.03.2022 at about 9.00 P.M., the injured/ petitioner namely Suraj Gupta , aged about 25 years, was going with his Vehicle no. HR 99 NK XXXX from Vasant Kunj to Laxmi Nagar, Delhi and the vehicle was being driven by the petitioner/ injured as per traffic rules and in a normal speed and on proper and correct side of the road, therefore, during the said process , when the petitioner / injured reached at Prithvi Raj Road, Aurenzeb Cut , New Delhi, a Maruti car bearing No. DL 1LS XXXX all of a suddent came in very high speed being driven by the respondent no.1in rash and negligent manner and in contravention of rules of traffic and hit the vehicle of the petitioner/ injured with very great force
…. Annexure -A
- Amount of compensation claimed as : Rs. 25,000/-
Interim award
- Reasons for claim of interim award : The petitiionr/ injured require
The interim relief amount for
His urgent needs as per rule
- Whether documents mentioned in sub : Yes
Rule(4) and sub rule(5) of rule20
have been annexed (give details)
PRAYER
It is , therefore, most respectfully and humbly prayed
that this Hon’ble Court may kindly pass an award in the sum of Rs. 5,00000/- ( Rupees Five Lacs Only) in favour of the petitioner and against the respondents jointly as well as severally together with interest thereon @ 12% P.A. from the date of filing of the claim petition, till realization of the compensation amount, under the provisions of section166 of M.V. Act.
It is further prayed that an interim award of Rs. 25,000/- (Rupees Twenty Five Thousand Only) with interest may also may be passed in favour of the petitioner and against the respondents, as provided U/s. 140 of the Motor Vehicle Act.
Any other relief or order which this Hon’ble Tribunal may think fit and proper also be awarded in favour of the petitioner and against the respondents.
PETITIONER
THROUGH
( Avinash Nandan Sharma)
Advocate
Ch.No.671, Patiala House Court,
New Delhi-1. Mob.8800794128
Place:
Date:
VERIFICATION
Verified at Delhi on this 17th Day of June , 2022 that the contents of the above application are true and correct to my knowledge and belief.
PETITIONER
ANNEXURE-A
due to which the petitioner fell down on the road and sustained multiple grievous injuries including bone fracture at right shoulder .
- That after the said accident, the petitioner /injured removed to Dr. RML Hospital, New Delhi, for treatment where MLC was made bearing No. E/555831/22. Thereafter, he remained under regular treatment in the said Hospital, being an OPD patient and also remained under treatment with the nearby private doctors.
- That the aforesaid accident took place solely due to the rash and negligent driving of the respondent no.1 who drove the offending vehicle at a very high speed, rashly and negligently. The respondent no.1 had driven his vehicle in contravention of all the traffic rules and norms and as such the respondent is entirely responsible for the said accident.
- That the injured/ petitioner was working as Accounts Assistant in a Private Company namely Hoteliers Pvt.Ltd. having its office at Building No. X, Vasant Kunj, New Delhi-110070 and was earning Rs. 16,000/- (Sixteen Thousand only) per month. That due to the said incident and displacement of bone at right shoulder, he was unable to continue with his job and suffered acute financial hardship.
- That the injured /petitioner has already incurred around Rs. 15,000/- on her treatment, medicines, conveyance, special diet etc. and is likely to incur more expenditures as he is still under treatment and to be operated by Surgeon.
- That apart from the above, the petitioner has also undergone extreme pains, shocks, agony, mental torture, stress, sufferings and inconvenience etc. resulting in shortening of her life.
- That the injured/ petitioner estimates the losses suffered by him on various accounts to the tune of Rs. 5,00000/- (Rupees Three Lacs only) at least.
- That the above accident was caused due to the sole negligence of respondent no.1 , who was driving the offending vehicle at the time of accident , respondent no.2 was the owner and respondent no.3 was the insurer of the offending vehicle. Therefore all the respondents are jointly as well as severally liable to pay compensation to the injured/ petitioner for the injuries sustained by her, in the aforesaid accident.
Petitioner
Through
(Avinash N. Sharma)
Advocate
Place:
Date:
IN THE COURT OF MOTOR ACCIDENT CLAIMS TRIBUNAL, NEW DELHI
PETITION NO._________ OF 2022
IN THE MATTER OF:
- SURAJ …. PETITIONER
VERSUS
- GUDDU KUMAR & ORS. …. RESPONDETS
AFFIDAVIT
I , Suraj , S/o sh. XX, R/o PRESENT ADDRESS-
Shakarpur, Delhi-92; PERMANENT ADDRESS-
House no. XX, Gorakhpur, U.P.
Do hereby solemnly affirm and declare as under:-
- That I am the petitioner and injured in the said claim petition.
- That I am filing the accompanying claim petition U/s. 166 & 140 of M.V. Act, and well conversant with the facts of the petition and the contents are true which are drafted by my counsel under my instruction and on my behalf and same are read over by me and reproduced herein for the sake of brevity.
- That I have engaged/ appointed Mr. Avinash N. Sharma, Advocate, to proceed my all the proceedings from filing the petition to its realization.
- That I have not filed any other or similar petition for the same purpose in any court of law, hence this petition.
Deponent
Verification:-
Verified at New Delhi on this 17th day of June , 2022, that the contents of the said affidavit are true and correct to the best of my knowledge and beliefs.
Deponent
IN THE COURT OF MOTOR ACCIDENT CLAIMS TRIBUNAL, NEW DELHI
PETITION NO._________ OF 2022
IN THE MATTER OF:
- SURAJ …. PETITIONER
VERSUS
- GUDDU KUMAR & ORS. …. RESPONDETS
LIST OF DOCUMENTS FILED BY THE PETITIONER
- Copy of ID proof of the petitioner ( Election Card, Driving Licence, &Pan Card)
- Copy of Certificate of 10th Board Exam, 10th + 2 Intermediate Exam, & Bachelor of Commerce Degree.
- Copy of the result card of CPT Test of The Institute of Charted Accountants of India, dated 02.12.2006
- Copy of Appointment Letter for the Post of Accounts Assistant, dated 18.12.2012.
- Copy of Salary Slip of Rs. 16,000/-
- Copy of Medical treatment , Prescriptions & Bills issued by RML Hospital, New Delhi , Som Datt Medical Centre , Shakarpur, Delhi, Consultant Ortho., RLKL Hospital, Pandav Nagar, Delhi.
- Photograph of the Injured/ Pettioner, Suraj Gupta
Petitioner
Through
(Avinash N. Sharma)
Advocate
Place:
Date:
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