IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT: O.P.NO. BETWEEN:Pet. Name and Add.

Petitioner AND Def. Name and Add. Respondents CLAIM: PETITION FOR COMPENSATION UNDER SEC.166 OF THE M.V. ACT, 1988 R/W SEC.163-A 140 (C) OF M.V. ACT, 1988 I. DESCRIPTION OF THE PETITIONER The description of the petitioner and address for the purpose service of all processes, notices etc., is the same as above mentioned in the cause tile and that of his counsel (name) II. DESCRIPTION OF THE RESPONDENT The description of the respondent and addresses for the purpose of service of all processes, notices etc., is the same as above mentioned in the cause title. I the above named petitioners having been injured in motor vehicle OF 2008

accident hereby apply for the grant of compensation for the injury sustained.

Necessary particulars in respect of the injury vehicle etc. are given below:Hereby apply, as legal respective agent for the grant of compensation on account of injury of who died in motor vehicle accident.

Necessary particulars in respect of the injured / deceased the vehicle are given below: 1. 2. 3 4 5 Name of Fathers name of the person Injured /deceased Full address of the person injured/deceased Age of the person injured / deceased Occupation of the person injured / deceased Name and address of employer of the injured / deceased Nil Nil

6 7 8 9

Monthly income of the person injured /deceased Does the person injured respect of where compensation is claimed pay income tax Place, Date, Time of the accident

Nil No

Name and address of the Police P.S. _____ has registered a case in Station injured whose jurisdiction the Crime No______ Under Section 337 accident took place of registered. of I.P.C against the driver of vehicle bearing No _____. Was the person injured respect of whom compensation is claimed traveling by the vehicle involved injured the accident if so give the name of places starting of journey and destination Nature of injuries sustained and continuing effect if any of the injury Name and address of the Medical The duty Medical Officer, Officer / Practitioner if any, attended on the injured / deceased Nature and period of the treatment Still under going treatment and expenditure if any, incurred thereon Disability for worker, if any accused Permanent disability Registration number and the type of the vehicle involved in the accident Name of address of the owner of the vehicle Name of address of the insurer of the vehicle Has any claim been lodged with the owner insurer and if so with result Whether the person injured / deceased had been involved in any road accident earlier Whether the person injured / deceased had preferred claim for damages in any case earlier and if so, with what result Whether he is related to or has know the defendant and if so how Name and address of the Applicant Vehicle bearing No As shown in the cause title of the Respondent NO 1 As shown in the cause title of the Respondent No2 No No No

10

11 12 13 14 15

17 18 19 20

21 22 23 24 25 (I)

No

As shown in the cause title of the Petitioner Relationship with the person injured / Not applicable deceased Title to the property of the deceased Not applicable Amount of Compensation claimed Rs

FOR SPECIAL DAMAGES Particulars of loss expenses (a) Loss of earnings from to (b) Partial loos of earning from (c Transport to Hospital to In all head the Petitioner claming Rs

(d) Extra nourishment and medicine (e) Damages to clothing and articles (f) II Others, scooter damage FOR GENERAL DAMAGES

(a) Compensation for pain and suffering (b) Compensation Under No fault liability C Compensation for the continuing or permanent disability, if any (d) Compensation for the loss of life / future earning powers and maintenance/ loss of consortium (Loos conjugal happiness) to the Petitioners 26 Any other information may be necessary or helpful in the disposal of the claim, the Petitioners submits as follows:

---------------------------Total Rs. ----------------------------

1.

That the Petitioner is permanent resident ------------. The claim

is an

(occupation and earnings) The claim petitioner used to get about Rs.-------/- per annum after excluding all expenses. 2. That on -------- the claim petitioner at about ------ p.m. was proceeding to

----------- from ----------- and at that time an crime vehicle coming from ------ in a rash and negligent manner with high speed dashed against the claim petitioner, due to which the claim petitioner fell down and sustained multiple grievous injuries. Immediately the injured was shifted to Dr. --------- Hospital. The accident occurred only due to rash and negligent driving of the driver of the auto. 3. 4. The claim petitioner sustained 1. ------------------------------(injuries) Immediately after the accident, the claim petitioner shifted to

-----------Hospital, , wherein X-rays were taken and other tests were conducted and a major surgery was conducted an implants were fixed. The claim petitioner took treatment for a period of -- days as in-patient. Later took treatment as outpatient for a period -------- months. The claim petitioner required another operation to remove the steel rods fixed in his leg. So far the claim petitioner spent about Rs.---------/- towards medical, attendant, operation and other extranourishment. 5. That on a complaint given by the brother of the claim petitioner, the Police, Dornakal registered a case in Cr.No. -------, u/sec. 338 of IPC against the driver of the crime vehicle. 6. That the petitioner was rather hale and healthy prior to the accident and was aged ---- years as on the date of accident. The claim petitioner is

Occupation. The claim petitioner used to -----------and getting about Rs.60,000/per annum after excluding all the expenses. The claim petitioner after the accident was advised to take bed rest for a period of 6 months completely. As such he could not attend to his agricultural fields sustaining a loss of Rs.-------/-. Even after 6 months period also the claim petitioner is not regular to his duties. The claim petitioner is unable to stand for a long time and could not able to walk freely on the paddy fields in view of injury to ---------. The Doctor advised the claim petitioner to take bed rest for a period of 6 months. In view of the accident and in view of the avocation of the claim petitioner, the claim petitioner sustained permanent disability. The accident was caused solely due to rash and negligent driving of the driver of the crime vehicle. Because of the untimely accident not only the claim petitioner, but his entire family suffered a lot. This caused much mental agony to the claim petitioner as well as to his family members apart from physical pain and suffering. 7. That on account of the injuries and hospitalization the claim petitioner spent about Rs.-----/-, the claim petitioner is claiming an amount of ------/- for special damages, Rs.--------- towards loss of earnings, Rs.-------/- towards partial loss of earnings, Rs.------- towards transport of the claim petitioner to hospital, Rs.------- towards pain and suffering, Rs.------/- towards permanent disability. In all the claim petitioner is claiming an amount of Rs.--------/- under special and general damages recovered from the Respondents. 8. That the respondent No.1 is the owner of the crime vehicle ie., bearing Registration No. ----------- and the respondent No.2 being the Insurer of the vehicle, as such respondents No.1 and 2 are jointly and severally liable to pay compensation to the claim petitioner. As per the Judgment of A.P. High Court ALT.2002 Part 2 Page 265 the driver of the vehicle need not made a party to the case. 9. That this is the first claim petition, no similar petition was filed earlier before this Honble Court or any other Tribunal either under sec. 166 or 140 of M.V. Act. 10. That the facts constituting the cause of action arose on ----------- at about _------- p.m. when the accident took place under the P.S. limits of -------- of --------District. As such this Honble Court has got jurisdiction to entertain the claim petition. 11. 12. That the claim petitioner is claiming an amount of Rs.----------/- as special That the claim petitioner is herewith filing all the documents pertaining to and general damages on which he paid Rs.-------/- towards Court the case for quick disposal of the O.P. The claim petitioner is herewith filing CC of FIR, CC of charge sheet and Medical Certificate. 13. That the claim petition is within limitation.

Hence, it is prayed that the Honble Court may be pleased to pass Judgment and decree in favour of the claim petitioner and against the person and properties of respondents jointly and severally, as follows a) To award an amount of Rs.--------/- to the claim petitioner under sec. 166 of M.V.Act towards general and special damages on account of injuries sustained by the claim petitioner, b) To award the interest @ 12% p.a. from the date of accident to till the date of realization of the claim petition; c) To award the costs of the claim petition, and

d) To grant any other, further relief or reliefs for which the Honble Court may deem fit and proper in the circumstances of the case. Khammam DTdd/mm/yyyy VERIFICATION I, Pet.Name the claim petitioner, do hereby declared that the contents of the claim petition mentioned above are true and correct to the best of my knowledge, belief and information. Hence, verified on this the day of , 2008. I also hereby verify and declare that no claim petition in regarding the same accident or in regarding the same cause of action has been instituted before any other Tribunal any where in India, except the present claim petition. Khammam DTdd/mm/yyyy CLAIM PETITIONER. ADVOCTE FOR THE CLAIM PETITIONER CLAIM PETITIONER.

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL

O.P.No. Between: Pet.Name

OF 2008

..Petitioner And Def name ..Respondents

CLAIM: PETITION FOR COMPENSATION UNDER SEC.166 OF THE M.V. ACT, 1988 R/W SEC.163-A 140 ( C )OF M.V. ACT, 1988

Filed on: dd/mm/yyyy

Filed by: M/s Counsel for Petitioner

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT: O.P.NO. BETWEEN:Pet.Name Petitioner AND Def name Respondents AFFIDAVIT I, Pet. name and add, do hereby solemnly and sincerely affirm and sincerely state on oath as follows: 1. case. 2. I submit that we had filed the above O.P for claiming the compensation I am the Petitioner here in as such I am well acquainted with facts of the OF 2008

before this Honble court on account of injuries sustained to my ______in the accident on ________ the P.S _______ has registered a case in crime No ________ under Section ______ of I.P.C against the driver of the _____. 3. I submit that I have not filed any petition before any court or authority for seeking same relief. Hence this affidavit. Sworn and signed before me On this the day of dd/mm/yyyy DEPONENT

Advocate/ Khammam

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT: O.P.NO. OF 2008

BETWEEN:Pet.Name Petitioner AND Def name Respondents THIRD PARTY AFFIDAVIT I Mr.___________, S/o.___________, aged about ___ years,

Occ:____________, R/o.______________, ________ District, solemnly affirm and state on oath as follows:-

do here by

1,

I am the Deponent herein and third party in the above proceedings,

as such I am will acquainted with facts of the case.

2,

I submit that I know the above named Petitioners since a long time

and they filed the O.P for compensation before this Honble court, the Petitioner is being minor under the care and custody of his father and natural guardian and he has having no adverse interest against the minor Petitioner claim.

Sworn and signed before me On this the day of dd/mm/yyyy, Khammam DEPONENT Advocate/ Khammam

Def name AND

Pet.Name

BETWEEN:

Nature of process to be issued for purpose for which money is deposited and order if any under which deposit made.

Date:dd/mm/yyyy petitioner O.P.No.

Def. Name and Add. OF 2008

Name and Description of Person on whom or on whose property the process is to be executed.

FORM No.61

(171 Payment into the Court of Cash/Process Fee Deposit)

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT:

It is requested that the sum of Rs.______ may be received from the purpose above mentioned.

Khammam
and fro the Court House.Travelling allowance to Class of Allowance Subsistence Allowance AMOUNT Process Fees Expenses of Sale or Commission

Advocate for Claim

Claim Petitioners

..Respondents

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT: O.P.No. OF 2008

BETWEEN: Pet.Name .Claim petitioner AND Def name Respondents.

PROCESS FORM

FILED ON: dd/mm/yyyy

FILED BY:

ADVOCATE FOR PLAINTIFF

VAKALATHNAMA
IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT:
O.P.No. BETWEEN: Pet.Name . Claim Petitioner AND Def name & another ..Respondents I, Pet. Name and Add., do hereby appoint and retain OF 2008

"Advocate name
Advocate Advocate/s to appear for me/us in the above Suit/Appeal/Petition/Case and to conduct and prosecute or defend the same and all proceedings that may be taken in respect of any application for execution of any decree or order passed therein. I/We empower my/our Advocate/s to appear in all miscellaneous proceedings in the above suit or matter till all decrees or order are fully satisfied, or adjusted, to compromise and obtain the return of documents and draw any money that might be payable to me/us in the said suit or matter and I/We do further empower my/our Advocate/s to accept on my/our behalf service of notice of all or any appeal or petition filed in any court or appeal Reference or Revision with regard to the said suit or matter before disposal of the same in Honorable Court.

I certified that the executant who is well acquainted with English, read this Vakalatnama that the contents of this Vakalatnama were read out and explained in Urdu/Hindi/Telugu to the executant he/she/they being unacquainted with English, who appeared perfectly to understand the same and signed or put his/her/their name or mark in my presence.

Identified by Sri

"
ADVOCATE

Executed on dd/mm/yyyy

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL AT:

BETWEEN: Pet.Name Claim Petitioner AND Def name Respondents

VAKALAT
ACCEPTED

FILED ON: dd/mm/yyyy FILED BY: ADVOCATE FOR Claim petitioner

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL

AT:
O.P.NO. Between: Pet.Name ... Claim petitioner AND Def name ... Respondents OF 2008

List of Document filed by Claim Petitioner

Sr.No 1 2

Date

Description

Claim Petitioner

Date: dd/mm/yyyy

Advocate for Claim Petitioner

IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL(PRL.DIST.JDGE)

AT: KHAMMAM
O.P NO. Between: Pet.Name ...Claim Petitioner AND Def name ...Respondents OF 2008

LIST OF DOCUMENTS

FILED ON: dd/mm/yyyy

FILED BY:

COUNSEL FOR CLAIM PETITIONER

FORM No.11 (In the matter of the M.V.Act 1939) MOTOR ACCIDENTS CLAIMS TRIBUNAL IN THE COURT OF THE MOTOR ACCIDENTS CLAIMS TRIBUNAL (PRINCIPAL DISTRICT JUDGE) AT KHAMMAM O.P.No. Between: Pet name ..Petitioner and Res name ..Respondent To Defendant add..
Whereas on the ____ the day of ______ 2008 the above named petitioner filed a petition against the respondents for the compensation under section 166 of M.V.Act 1988 and Rules 514 of A.P.M.V.Rule 1964 you are hereby required to appear to in this court on _______ the day of _______ 2008 at 10-30 AM in person or by pleader duly instructed able to answer all material questions relating to the above proceedings. Also take notice that in default of your appear5ance on the aforesaid day this issues will be settled and the petitioner heard and determined in your absence. You shall also bring with you are send by your pleader any documents on which intend to reply in support or defence. You are required to file a written statement in Court before the ____ day of ______ 2008. Given under my hand and the seal of the court this day of _____ 2008.

OF 2008

SEAL

By order NAZIR

Note: A copy of the petition accompanies the notice. 1. This Notice should be received not less than 21 days before the day (fixed above for settlement of issues.) 2. This notice should be appended your witness will not attend on their own accord such can have summon issued from this Court to compel of any witness and the production of any document. You have a right to call This notice has been taken out by Advocate name , Advocate Counsel for petitioner

Pet. Name and Add.

Pet. Name and Add.