BEFORE THE MOTOR ACCIDENTS CLAIMS TRIBUNAL, PALA

O.P. (M.V) No. /2022

Petitioner Respondents

(Driver)

Mob.

(Owner)

(Insurer of the vehicle)

PETITION
FILED UNDER SEC. 140 and 166 OF THE MOTOR VEHICLES ACT, 1988.
I, , aged years, S/o ,
House, P.O., do hereby apply for grant of
compensation for the injury sustained to me in a motor vehicle accident.
Necessary particulars in respect of injury, vehicle etc., are given below.
1. Name of the person injured Laila Beevi

2. Full address of the person injured Idasseriyil, Chathanthara P.O,

Kollamula Village, Pathanamthitta Dt.,
Kerala, Pin:686510
3. Age and date of birth of the years,
person injured or dead (to be
supported by documentary Date of Birth:
evidence if available)

4. Occupation of the injured

5. Name and address of the Nil

employer of the person injured
6. Monthly income of the injured

7. Does the person in respect of

whom compensation is claimed
pay income tax?

8. Place, date and time of the Occurred on 02/07/2023 at 02:30 P.M.

accident on Manarkadu-Ettumanoor Bypass Rd at
Kurisupally, Ayarkunnam.

9. Name and address of police Ayarkunnam Police Station,

station in whose jurisdiction the Crime number. 726/2023
accident took place or registered

10. Was the person in respect of : Yes.

whom compensation is claimed
traveling by the vehicles involved
in the accident? If so, give the
name of the places of starting
journey and destination.

11. Nature of injuries sustained:

(a) Abrasion of size 1x0.5cm left upper eye lid,
(b) Swelling of size 10x7cm over frontal region,
(c) cystic in consistency Non-Tender

Name and address of the Medical : Dr. Jiby Eapen Mathew, General
12. Officer, who attended on the Surgeon, Caritas Hospital, Th ellokom,
injured Kottayam.

13. Period of treatment and
expenditure if any incurred
thereon (to be supported by
documentary evidence)
After the accident the patient was taken
to Caritas Hospital Kottayam and treated
as an inpatient. The petitioner was
admitted in the hospital for 4 days and
medical expenses are narrated in column
No.28

14. Disability for work, if any caused

15. Registration number and type of

the vehicle involved in the
accident

16. Name and address of the owner

of the vehicle

17. Name and address of the insurer

 of the vehicle
18 Policy particulars of the vehicles
or vehicles involved if available
19. Name and address of the driver of
the vehicle
20 Details of driving license of the
driver or drivers of the vehicle or
vehicles involved if available
.21 Has any claimed lodged with the
owner or insurer ? If so, what
result?

22. Has any other claim being lodged

in any other forum in respect of
the same cause of action? If so,
with what result?

23 Name and address of the

applicant

24. Relationship with the deceased

25. Title to the property of the
deceased

26. Amount of compensation claimed Rs.

27. Particulars of loss of expenses Stated below
28. Other particulars, if any, which Stated below
the applicant wishes to give

Part I
a. Loss of earnings : Rs.
b. Partial loss of earnings :
c. Transport to hospital : Rs.
d. Extra nourishment : Rs.
e. Damage to clothing and articles : Rs.
f. Others
(i) Treatment expenses : Rs.
(ii) Bystander Expenses : Rs.
(iii) Expenses for bystander
Accommodation and food : Rs.
(iv) Compensation for future treatment
expenses : Rs.
PART II
g. Compensation for pain and
Sufferings : Rs.
 h. Compensation for loss of
earning power : Rs.
i. Compensation for loss of
Amenities : Rs.
-------------------
Total : Rs.
=============
The claim is limited for the purpose of Court Fee at Rs.

29. Whether the injured / deceased had

had Involved in any other road
accident earlier
(in case he was, state details) : No

30. Whether any application has been

prepared by any other legal heirs
on the same claim? If so, state details : NA
:
31 Has any claim been filed by any other
Injured in respect of the same accident?
If so, State details, if available : No

32 Any other information that may be necessary or helpful in the disposal of the
claim:

The accident alleged was due to the rash and negligent driving of the 1 st
respondent herein. Police on investigation laid charge sheet against the 1 st respondent
herein under Sec. 279,337 and 338 of IPC. The said Creta car bearing No. KL /
was registered in the name of the respondent and the vehicle was insured with the
respondent herein. Hence all the respondents are jointly and severally liable to pay
compensation to the petitioner herein. That the cause of action is within the jurisdiction
of this Tribunal at within the jurisdiction of Police Station within the
jurisdiction of this Hon’ble Tribunal and hence this claim petition is maintainable before
this Hon’ble Tribunal.
A Court fee of Rs. is payable under rule 397 of Kerala Motor Vehicle
Rules 1989, and Rs. is payable under Kerala Legal Benefit Fund. At present
petitioner is unable to pay the same and is filing an exemption petition for payment of
Court Fee and Legal Benefit Fund.
Hence it is humbly prayed and submitted that the Hon’ble Tribunal may be
pleased to pass an award of Rs. with 12% interest from the date of petition till
realisation and costs of these proceedings from the respondents jointly and severally
from their assets and to allow other relief which this Hon’ble Tribunal deems just and
proper as prayed for during the Course of these proceedings.

Dated this the day of 2022

Petitioner :

Advocate :

I, Mathew Chacko S/o Chacko do hereby declare that all the facts stated above
are true and correct to the best of my knowledge, information and belief.
Petitioner :

Advocate :

Documents

1. Photo copy of the FIR

2. Photo copy of the FIS

3. Photo copy of the Scene Makassar

4. Photo copy of the AMVI report

5. Photo copy of the wound certificate

6. Photo copy of the police final report

7. Photo copy of the Adhar of the petitioner

8. Copy of the bank pass book of the petitioner.

9. Copy of the of the petitioner to prove the age of the petitioner.

Dated this the day of October 2022.

Advocate :