IN THE COURT OF THE MOTOR ACCIDENT CLAIMS TRIBUNAL

DELHI,

(PRESIDED BY SH: ARVIND KUMAR, ADJ/ASJ, EAST DELHI.)

In Re:-
SMT: KIRTI GUPTA, W/O SH.SANJAY KUMAR GUPTA

R/O H.NO.A-43, VIVEK VIHAR,DELHI-92.

PETITI
ONERS

VERSUS

(1). SH: VINAY KUMAR AGGARWAL, S/O SH. VRIJ BHUSHAN AGGARWAL,
R/O –1/4980, GALI NO-1,
BALBIR NAGAR EXTN.SHAHDRA, DELHI ……………………….DRIVER

(2).SH:ROSHAN LAL,S/O SH:BHARTU MAL,

R/O- 1/4980, GALI NO-1,
BALBIR NAGAR EXTN.SHAHDRA, DELHI
.………………….OWNER.

(3).NATIONAL INSURANCE CO.P.LTD.

OFFICE – 28, SCOPE MINAR, 11TH FLOOR, CORE-2,
DISTRICT CENTRE, NORTH TOWER,
LAXMI NAGAR, DELHI-92.……………………………………………………INSURANCE
COMPANY

POLICY NO.(361303/31/12/6100005098)

RESPODENTS
APPLICATION FOR GRANT OF COMPENSATION UNDER SECTION THE
166 & 140 OF MOTOR VEHICLE ACT 1988
(AMENDED UPTO DATE)

Sir,
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

1. Name & Father’s name of SMT. KIRTI GUPTA,

the person injured/dead
(Husband’s name in case W/O SH:SANJAY KUMAR GUPTA.
Of married women & widow).

2. Full address of the person AS MENTIONED ABOVE FOR

Injured/dead. THE PETITIONERS.

3. Age of the person injured dead 41 years.

4. Occupation of the person injured! FINANCIAL ADVISOR

Dead.

5. Name & Address of the employer of FINANCIAL ADVISOR

The injured/dead.

6. Monthly income of the person 30,000 P.M

Injured/dead.

7. Does the person in respect of

whom compensation is claimed YES(ACTPG1480D)
pay income Tax? (to be supported
by document).

8. Brief particulars of the accident --AS PER ANNEXTURE“A”-----

9. Place,date and time of accident NEAR “C”BLOCK,VIVEK VIHAR,

DELHI-110092.

AT ABOUT-01.45 P.M. ON
(18/12/2012).
 10. Name & Address of Police Station
In whose jurisdiction the accident
accident took place was registered.
11. Was the person in respect of whom?
Compensation is claimed traveling
by the vehicle involved in the
accident? If so, give the Name. &
Place of starting the journey and
Destination.
12. Name of the injuries sustained
13. Name & Address of the Medical
Officier/Practitioner If any who
attended on the injuries.
14. Period of treatment and
Expenditure If any incurred.
15. Registration No. & type of
Vehicle involved in accident
F.I.R.NO. 377/12, DT.
(18/12/2012).U/S279/338 I.P.C
POLICE STATION VIVEK VIHAR
VIHAR,
DELHI.
“YES”THE PETITIONER WAS TRAVELLING
ON HER BATTERY SCOOTER ALONGWITH
HER SOM MASTER ARCHIT.DRIVING
IN A MODERATE SPEED QUITE
QUATIOUSLY FOLLOWING RULES OF
ROAD.
COMMINUTED FRACTURES LOWER END
OF RADIUS AND ULNA
STYLOID AND OTHER
GREVIOUS INJURIES AS PER
MEDICAL
RECORDS.
MEDICAL SUPRITENDENT
AT PUSHPANJALI MEDICAL CENTRE
NEW DELHI.
THE PETITIONER WAS IMMEDIATELY
HOSPITALIZED ON 18/12/12 AT
PUSHPANJALI MEDICAL
CENTRE,DELHI IN A PATHETIC
CONDITION. TREATMENT WAS
GIVEN BUT SHE IS IN VERY
CRITICAL OPERATION DONE ON
19/12/12 AND DISCHARGED ON
21/12/2012.SEVERAL OPERATIONS
WERE DONE TO SAVE THE LIFE OF
PETITIONER. EXPENSES INCURRED
ON TREATMENT RS.2,00,000/-.
CAR BEARING NO.
DL-5CD-4556
16. Name & Address of owner of
OFFENDING vehicle.
17. Name & Address of driver of
OFFENDING vehicle.
18. Name & Address of the insurer
Of the vehicle.
19. Has any claim been lodged with
the owner/insurer, if so, what
Result.
20. Name & Address of the applicant
21. Relationship with the deceased/
Injured.
22. Title of the property of the
deceased/injured
23. Amount of compensation claimed.
24. Whether reports from the Police
And the Registering authority
Have been obtained in form “A”
And “D” (if so, to be annexed)
AS PER RESPONDENT NO.2
SH: VINAY KUMAR AGGARWAL,
S/O SH. VRIJ BHUSHAN AGGARWAL,
R/O-
1/4980, GALI NO-1,
BALBIR NAGAR EXTN.SHAHDRA,
DELHI.
AS PER RESPONDENT NO.3.
-----------NO------------
AS MENTIONED ABOVE FOR
PETITIONERS.
---------SELF---------
---------SELF---------
Rs.10,00,000/-
(RUPEES TEN LAKHS ONLY.)
The report of IO in
form “A” & form “D”
will be obtain and
will be filed mean
while.
25. Whether affidavit of the applicant YES.
And witnessed as per rule 8 are
Annexed (give details).

26. Whether documents mentioned in NO.

Rule 8 are being annexed duly
Indexed (give details).

27. Any other information that may ----AS PER ANNEXURE “A”--
By necessary and helpful in the
Disposal of the case.

PART-II

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

28. Amount of compensation Rs. 25,000/-(Rs. TWENTY FIVE

Claimed as interim award. Thousand)

29. Reasons for claim of interim SERIOUSLY INJURED AND FOR FURTHER
Award.
TREATMENT.

30. Whether documents mentioned Yes, some documents filed

In sub rule (4) and sub rule and remained will be filed
(5)of rule 20 have been anne- mean while.
xed (give details).