Draft Of MOTOR ACCIDENT CLAIMS TRIBUNAL(MACT)

 Form  ‘G’

      (See Rule 8 and 20)

Application for grant of compensation under the Motor Vehicles Act, 1988

BEFORE MOTOR ACCIDENT CLAIMS TRIBUNAL , DELHI

1. 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

1. Guddu Kumar S/o Sh. XX,

R/o H.No. Y, Village Z,                              ….  Driver

 

2. Todar Mal S/o. XX,

R/o. H.No. X, Okhala , New Delhi            ….. Owner

 

3. The Insurance Company. Ltd.

Off: 12XX, 20^th 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,

1. Name & Father’s Name of the person :  Suraj , S/o XX,

injured/dead (Husband’s Name in the

case of married woman & widow)

 

2. Full address of the person injured/ :  As above mentioned.

dead.

 

3. Age of the person injured/dead :  25 Years

 

4. Occupation of the person injured/ :  Private job as Account Assistant.

dead.

5. Name & address of the employer of :  M/s.  Hoteliers

the injured/dead                                               Pvt. Ltd.,  Off. Building No.X,

, New Delhi

 

6. Monthly income of the person injured/ :  16,000/-     Per Month.

dead.

7. 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).

 

8. Place, date and time of accident. :  P R Road, Auranzeb Lane cut,

New Delhi on Dt. 28.03.2022 at

About 9 P.M.

9. 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.

 

10. 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.

 

11. 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.

 

12. Nature of the injuries sustained and :  Grievous Hurt, Bone Fracture in

disablement, if any, caused                          right shoulder  along with sever

Injuries and pain.

13. Name & Adress of the Medical :  Doctors of RML Hospital,

Officer/ Practitioner if any who                          New Delhi

attended on the injuries.

 

14. Period of treatment and expenditure :  10,000 spent on treatment

if any incurred                                                and treatment is still continue.

 

15. Registration No. and type of vehicle : DL 1LS XXXX, Maruti Car

involved in the accident

16. Name and address of owner of the : Respondent No. 2

Vehicle.

17. Name and address of driver of the : Respondent No. 1

Vehicle.

18. Name and address of Insurer of the : Respondent No. 3

Vehicle.

19. Has any claim been lodged with the :     –     A.      –

owner/ insurer, if so, with what result.

20. Name and address of the applicant. : As per title of the claim petition

 

21. Relationship with the deceased/injured :   –     Self      –

 

22. Title of the property of the deceased/injured :  –    A.  –

 

23. Amount of compensation claimed & : Rs. 5,00,000 ( Rupees five

basis thereof.                                                      Lakhs only)

24. Whether reports from the police and

The Registering Authority have been             : –   Yes    –

obtained in Form ‘A’ & ‘D’ ( if so to be

annexed).

25. Whether affidavit of the applicant and –    Yes    –

witnesses as per rule 8 are annexed

(give details)

 

26. Whether documents mentioned in rule 8 :  –    Yes    –

are being annexed duly indexed

( give details)

 

27. Any other information that may be

necessary and helpful in the disposal

of the case.

1. 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

28. Amount of compensation claimed as : Rs. 25,000/-

Interim award

29. Reasons for claim of interim award : The petitiionr/ injured require

The interim relief amount for

His urgent needs as per rule

30. 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 .

2. 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.
3.  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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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:

1. SURAJ                             …. PETITIONER

VERSUS

1. 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:-

1. That I am the petitioner and injured in the said claim petition.

 

2. 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.

 

3. That I have engaged/ appointed Mr. Avinash N. Sharma, Advocate, to proceed my all the proceedings from filing the petition to its realization.

 

4. 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 17^th     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:

1. SURAJ                                …. PETITIONER

VERSUS

1. GUDDU KUMAR & ORS. …. RESPONDETS

 

LIST OF DOCUMENTS FILED BY THE PETITIONER

1. Copy of ID proof of the petitioner ( Election Card, Driving Licence, &Pan Card)
2. Copy of Certificate of 10^th Board Exam, 10^th + 2 Intermediate Exam, & Bachelor of Commerce Degree.
3. Copy of the result card of CPT Test of The Institute of Charted Accountants of India, dated 02.12.2006
4. Copy of Appointment Letter for the Post of Accounts Assistant, dated 18.12.2012.
5. Copy of Salary Slip of Rs. 16,000/-
6. 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.
7. Photograph of the Injured/ Pettioner, Suraj Gupta

 

                                                      Petitioner

                          Through

 

                                       (Avinash N. Sharma)

                                                                          Advocate

Place:

Date: