Motor Accident Compensation Claim Form - Application Under Section 140 and 166 of Motor Vehicles Act - Form Download in MS Word Format

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Application for Payment of

Compensation under
Section 140 and 166 of
Motor Vehicles Act, 1988
for claiming motor
accident compensation
before the Motor Accident
Claims Tribunal.
Format of Claim Petition to be filed
before the Motor Accident Claims
Tribunal to claim Motor Accident
Compensation by the victim or
family or dependent.
Application before the Motor Accidents Claims

Tribunal should be filed with all the documents like
normal Petition and with the below given application
form. The Petition should include:

429
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1. Memo of Parties
2. Application under Section 140 and 166 of the Motor
Vehicles Act 1988 for grant of compensation along
with affidavit in Support.
3. List of documents with documents
4. Vakalatnama
Format of Application under Section 140 and 160 of

Motor Vehciles Act, 1988 is given below:
अपना समुदाय ढूंढ़ें

साइन अप करें , भागीदारी करें और अपने
समु दाय को आज ही प्राप्त करें
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साइन अप करें
BEFORE THE MOTOR ACCIDENT CLAIMS

TRIBUNAL_________
CLAIM PETITION NO. __________ OF 20__
IN THE MATTER OF:
Mr. _________
CLAIMANT
New Delhi
429
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VERSUS
1. Mr. ____________
RESPONDENT NO.1
(DRIVER)
2. Mr. ____________
RESPONDENT NO.2
(OWNER)
3. ______________ Insurance Company Ltd
RESPONDENT NO.2
(INSURANCE COMPANY)
POLICE STATION: _______________
APPLICATION FOR PAYMENT OF COMPENSATION

UNDER SECTION 140 AND 166 OF MOTOR VEHICLES
ACT, 1988
Name and Father's Name of Mr. _______________

1.
the Person injured s/o Mr. ______
Full address of the Person

2.
injured
3. Age of the Person injured
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Occupation of the Person
4.
injured
Name & Address of the

5.
Employer of the injured
Monthly Income of the

6.
person injured
Does the person in respect

of whom compensation is
7. claimed pay income tax? If
so state the amount of

income tax
Place, date and time of

8.
accident
Brief particulars of the

9.
accident
Name and address of the

Police station in whose
10.
jurisdiction accident took
place or was registered
Was the person in respect

of whom compensation is
claimed traveling by the
11. vehicle involved in the

accident? If so give the
name and place of starting
the journey and destination
Nature of Injuries sustained
12. and disablement, if any,

caused
13. Name and address of the

Medical Officer/
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Practitioner, if any who
attended the injuries
Period of treatment and

14.
expenditure if any incurred
Registration Number and
15. type of vehicle involved in

the Accident
Name and Address of the

16.
owner of the vehicle
Name and address of Driver

17.
of the Offending Vehicle
Name and address of the

18.
insurer of the vehicle
Has any claim been lodged

with the owner, insure if so,
19.
by the Applicant with what
result
Name and Address of the

20.
Applicant
21. Relationship with diseased
Title of the Property of the

22.
deceased
e.g. Pecuniary loss

of earning, Medical
Amount of Compensation
23. Expenses, Loss on
claimed and basis thereof
account of Mental
agony etc..
24. Whether reports from the

police and Registering
Authority have been
429 obtained in Form "A" and

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Form "D" (If so, to be
annexed)
Whether affidavit of the

Applicant and witnesses as
25.
per rule 8 are annexed (give
details)
Whether documents
mentioned in Rule 8 are

26.
being annexed duly indexed
(give details)
Any other information that

may be necessary and
27.
helpful in the disposal of
the case
PART II
(To be filled if prayer is made for interim award)
Amount of
compensation
28.
claimed as interim
award
Reason for claim of e.g. claimant is

29.
interim award bedridden etc
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Whether documents
mentioned in sub-
rule (4) and sub-rule
30.
(5) of rule 20 have
been annexed (give
details)
e.g. It is therefore most

respectfully prayed that
the Petitioner may be
awarded a
compensation of Rs. ;
and
If is further, most
respectfully prayed that
the Claimants may be
awarded compensation
31. Prayer
under Section 140 of the
Motor Vehicles Act,
1988.
Any other or further

relief as this Hon'ble
Tribunal may deem fit
and proper in the facts
and circumstances of
the case as may be
made.
PETITIONER
429
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THROUGH
______________., Advocate
Place :
Date :
VERIFICATION
I, ____________, the above named claimant do hereby

verify that the contents of Para 1 to 31 of the Claim
Petition are true and correct to the best of my
knowledge and belief and those of legal averments
are true and correct on the basis of legal advice
received and believed to be true by me. The last para
is the prayer to this Hon'ble Tribunal
Verified at ____ on this ______ day of _____ 20__
PETITIONER

TRIBUNAL_________
IN THE MATTER OF:
Mr. _________
PETITIONER
429VERSUS
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Mr. ____________ & ORS
RESPONDENTS
AFFIDAVIT
I, _______, the above named Deponent do hereby

solemnly affirm and state as under:
1. That I am the Claimant herein and as such am well

conversant with the facts and circumstances of the
present case and hence am competent to swear this
Affidavit.
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2. That the statement of facts accompanying Claim

Petition has been drafted under my instructions and
the contents thereof, except the legal averments
contained therein, are true and correct to the best of
my knowledge and belief. The legal averments
contained therein are true and correct on the basis of
the legal advice received by me and believed by me to
be true tree and correct. The contents of the Petition
not being repeated over here for the sake of brevity
and to avoid prolixity.
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3. That the deponent declares that no such claim,
either before this Hon'ble Tribunal or any other
Tribunal or any other Court has been preferred by the

Claimants either in Delhi or at any other place.
4. That the Deponent had never been involved in any

earlier road accident and no tribunal had ever granted/
made liable, for any compensation arising out of any
motor vehicle accident.
5. That no part of this affidavit is false and no

materials facts have been concealed therefrom.
DEPONENT
I, __________, the above named Deponent, do hereby

verify that the contents of the Present affidavit are
true and correct to the best of my knowledge and
belief, and no part of it is false and no material facts
have been concealed therefrom.
Verified at _________ on this ___ day of ____ 20__
DEPONENT

TRIBUNAL_________
IN THE MATTER OF:
Mr. _________
PETITIONER
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VERSUS
Mr. ____________ & ORS

RESPONDENTS
LIST OF DOCUMENTS WITH DOCUMENTS
S. PAGE
PARTICULARS
NO NO
1. Copy of FIR
2. Copy of Medical Record dated ____
3. Copy of Aadhar Card of Petitioner
4. Copy of PAN Card of Petitioner
5. Copy of Driving License of Petitioner
6. Copy of Medical Bills
7. Copy of Income Tax Returns of Petitioner
Copy of Insurance Certificate of

8. Respondent No. 2 issued by Respondent
No. 3
A table showing Petitioner's Medical

9.
Expenses as on ________
10. Brief Particulars of the Accident
THROUGH
______________., Advocate
Place :
Date :
Download format of Application under Section 140
429and 166 of Motor Vehicles Act 1988 in MS Word

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CPC CRPC IPC Legal Formats

Application for Payment of

Application before the Motor Accidents Claims

normal Petition and with the below given application

form. The Petition should include:

2. Application under Section 140 and 166 of the Motor

Vehicles Act 1988 for grant of compensation along

with affidavit in Support.

3. List of documents with documents

Format of Application under Section 140 and 160 of

अपना समुदाय ढूंढ़ें

BEFORE THE MOTOR ACCIDENT CLAIMS

CLAIM PETITION NO. __________ OF 20__

IN THE MATTER OF:

3. ______________ Insurance Company Ltd

POLICE STATION: _______________

APPLICATION FOR PAYMENT OF COMPENSATION

Name and Father's Name of Mr. _______________

Full address of the Person

3. Age of the Person injured

Name & Address of the

Monthly Income of the

Does the person in respect

so state the amount of

Place, date and time of

Brief particulars of the

Name and address of the

place or was registered

Was the person in respect

11. vehicle involved in the

Nature of Injuries sustained

12. and disablement, if any,

13. Name and address of the

attended the injuries

Period of treatment and

Registration Number and

15. type of vehicle involved in

Name and Address of the

Name and address of Driver

Name and address of the

Has any claim been lodged

Name and Address of the

21. Relationship with diseased

Title of the Property of the

e.g. Pecuniary loss

24. Whether reports from the

429 obtained in Form "A" and

Whether affidavit of the

mentioned in Rule 8 are

Any other information that

(To be filled if prayer is made for interim award)

Reason for claim of e.g. claimant is

e.g. It is therefore most

Any other or further

I, ____________, the above named claimant do hereby

Verified at ____ on this ______ day of _____ 20__

BEFORE THE MOTOR ACCIDENT CLAIMS

CLAIM PETITION NO. ________ OF 20

Verified at on this day of _ 20

CLAIM PETITION NO. ________ OF 20

Verified at _______ on this _ day of __ 20

CLAIM PETITION NO. ________ OF 20