IN THE COURT OF MOTOR ACCIDENT CLAIMS TRIBUNAL AT ____________

MAC No:_______ of 2____

Petitioner 

Versus

Respondents 

Petition Under Section 166 of the Motor Vehicles Act for the Grant of Compensation to the Petitioner on Account of Damage to his _________

Respectfully Sheweth: 

I, , the above named petitioner, do hereby apply for the grant of compensation loss/damage sustained to my property described as _____ by use of Motor Vehicle of the respondent No. ______. The necessary particulars of the _____ in question are given as under:- 

1. Name and father's name of the claimant: Same as given in memo of parties above. 

2. Full address of the property: Resident of : _______

3. Age of the injured: _______ Years. 

4. Occupation of the injured: _______ presently 

5. Name and address of the deceased/injured : Resident: _______ 

6. Did the person in whose respect compensation is claimed pay income tax : ______-_Yes/No 

7. Monthly income : Rs. _______ 

8. Place, date and time of accident : Accident took place at _______ 

9. Name of police station : PS : _______ 

10. Was the person in whose respect the compensation is claimed traveling in the bus and if so than the place of start of journey & destination: The person in whose respect the compensation is being claimed was traveling in the _______ 

11. Nature of the loss/injury sustained by the property: The _______ 

12. Name and address of the person who attended/visited the property: _______

13. Period of treatment and expenditure: The injured/deceased remained under treatment from _______ 

14. Registration and type of vehicle involved in the accident: Regn No. _______

15. Name of the insurer: _______ 

16. Has any claim been lodged with the insurer : _________ 

17. Name and address of the owner of the vehicles: Same as given in memo of parties above. 

18. Name and address of the applicant: Same as given in memo of parties above. 

19. Relation with the deceased/injured : The petitioner _______ 

20. Title to the property : The _______ 

21. Amount of compensation: - Injury _______ - Love & Affection _______ - Medical Expenses _______ - Damages _______ - Pain & mental Agonies _______ - Loss of Marital Bliss _______ Total ______________ 

22. Any other information which may be necessary for the disposal of the claim: The ________ 

23. Reasons or grounds for late submission of claim application on which condonation of delay is claimed. The claim application is within the period of limitation. 

24. Cause of Accident with brief description : The accident took place due to rash and negligent driving of the driver of the vehicle. __ It is, therefore, respectfully prayed that the petition may kindly be allowed and the petitioner may kindly be awarded compensation amounting to Rs. _____ as ____ and interest thereon @18% per annum till payment against all the respondents jointly and severally.

Petitioner 

_______ 

Through, Advocate 

Verification:

I, the above named deponent do hereby verify that the contents of this affidavit of mine are true and correct to the best of my knowledge and belief. 

Verified at _______ this the -- day of ._______ Petitioner