IN THE COURT OF COMMISSIONER FOR

EMPLOYEES’(WORKMENS) COMPENSATION FOR THANE

APPLICATION(WCA) NO. OF 2023

1) Smt. Hasnahara Begum Israil Sk)

aged 36 yrs , widow of the deceased )

2) Ku. Mabina Khatu Israil Sekh )

aged 12 yrs., daughter of the deceased )

3) Master Momin Israil Sekh )

Aged 65 yrs., Son of the deceased)

4) Smt. Nur Salima Bibi Islam Sk )

aged 55 yrs , mother of the deceased )

5) Mr. Islam Jahadar Seikh )

aged 70 yrs , father of the deceased )

all the above Applicants are at present )

residing at: 501 (1) Berugeram Kulutiya
Braddhaman, Sadipur, West Bengal ) ...Applicants

V/s

Mr. Saifulla Anwar Daras Shaikh

At:- R.No.102, Sai Ujala Apt.Ulhasnagr
No.03, Tal- Kalyan Dist-Thane 421003
(Owner of Vehicle No. MH-05-EX-1786 ) ...Opp. Party

And

Magma HDI Gen.Ins.Co.Ltd..

having their office at Unit No.63, 6th Floor,
Der Deutsche Parkz near Nahur Railway
Station, Bhandup, Mumbai – 400078
Policy No:- P0024200040/4103/100336 )
Validity :- 18/08/2023 to 17/08/2024 ) ….insurer

____________________________________________________

Application for CompensationU.S. 22, 4,4-A,

10 R/W (Ruke) of Employees’ (Workmen’s)

Compensation Act( amended 2009)

___________________________________________________
MAY IT PLEASE YOUR HONOUR :-

It is stated , submitted , and prayed on behalf of the Applicant as under:-

1) The Applicant No. 1 is widow of the deceased, Applicant No. 2 is

daughter of the deceased, Applicant no. 3 is Son of deceased,

applicant no. 4 is Mother of deceased and applicant No. 5 is Father of

deceased Mr. Butes @ Israil Sk Islam Sekh.

2) By way of Present Application, the Applicant is claiming for grant of

compensation from this Hon'ble Court under
Employees’(Workmen’s) Compensation Act( amended 2009) as the
deceased Mr. Butes @ Israil Sk Islam Sekh expired due to
sustained serious injuries in Motor Vehicle accident which arising out
of and in course of his employment with opposite party as Driver on
Motor Vehicle bearing No. MH-05-EX-1786 which is duly insured
with Magma HDI Gen. Ins. Co. Ltd.

3) The Applicant submit that deceased Mr. Butes @ Israil Sk Islam

Sekh was a Driver employed with the Opposite Party and was
worked on Motor Vehicle bearing No. MH-05-EX-1786 On
20/11/2023, the deceased Mr. Butes @ Israil Sk Islam Sekh while
on his regular duty on Motor Vehicle bearing No. MH-05-EX-1786
met with an accident due to which he sustained serious injuries and
expired on the spot.
4) immediately after accident Mr. Butes @ Israil Sk Islam Sekh was
moved to Rural Hospital,Kasara Tal-Shahapur Dist-Thane, for
treatment but before admission he declared dead, and thereafter Post
Mortem was performed at Rural Hospital,Kasara Tal-Shahapur
Dist-Thane The Applicants craves leave to refer to and rely upon the
Medical papers and Police Papers which is annexed with this
application.

5) The Applicants submit that above accident was registered with

Kasara Police Station vide C R No. 194/2023 Tal- Shahpur, Dist.
Thane.

6) The Applicants submit that Post-mortem was performed at Rural

Hospital,Kasara Tal-Shahapur Dist-Thane, Annexed herewith a

Copy of Cause Of Death & P M Report .

7) The Applicants submits that they lost their only earning member .
The Deceased was maintaining the family and he was a only earning
member of the family. The Applicants submit that due to the death of
Mr. Butes @ Israil Sk Islam Sekh the Applicants have been
deprived of the source of maintenance which were provided by the
deceased . After the accidental death, there is nobody to look after the
Applicants.

8) That all the Applicants were fully dependant on the deceased Mr.
Butes @ Israil Sk Islam Sekh. There is in fact no other person
 earning the livelihood for the Applicants. So also, there is no other
source of income for the Applicants for their maintenance . The
Applicants submits that they are undergoing great and unbearable
pain and suffering since the death of the deceased.

9) The Applicants states that the deceased Mr. Butes @ Israil Sk Islam
Sekh was expired while in the course of his employment with the
Opp.party . The deceased Mr. Butes @ Israil Sk Islam Sekh was
aged 41 years and was getting salary of Rs.15,000/-p.m = Rs. 100
Bhatta per day at the time of accident.
5

10) The Applicants submits that the owner i.e. Opp. party and the Insurer
were in the knowledge of the aforesaid accident as the Opp. party
attended funeral ceremonies of Mr. Butes @ Israil Sk Islam Sekh
also and the Applicant had personally visited at the office of the
opp.party and lodged his claim for compensation with him however
he was advised by the opp. party that as his vehicle is duly insured
therefore he should lodged his claim with insurer and for which he
ready to furnish necessary documents .

11) That the Applicants are in the application are only dependent legal
heirs of the deceased Mr. Butes @ Israil Sk Islam Sekh and there is
no other legal heir than the present applicants .

12) That at the time the death of Mr. Butes @ Israil Sk Islam Sekh was
aged 41 years and was and earning Rs.15,000/-p.m + Rs. 100/- /- per
day Bhatta. As per the Workmen’s compensation Act if age is taken
as 41 yrs the factor for this is 181.37 and average monthly income is
 Rs.15000/- p.m . Multiplying 50% of Rs. 15000/- i.e. Rs. 7,500/-
with factor 181.37 the amount comes to Rs. 13,60,275/- ( Rupees
Thirteen Lac sixty thousand two hundred seventy Five only) and
for which the Applicants are entitled as a legal heir and legal
representative of the deceased

13) In these circumstances, the opposite party and the Insurer are jointly,

severally and vicariously liable to pay the amount of

compensation/damages i.e Rs. 13,60,275/- ( Rupees Thirteen Lac

sixty thousand two hundred seventy Five only) to the Applicants .

14) The Applicants states that they seeks liberty of this Hon'ble Court to
add,amend and/or alter the application if the need so arises.

15) That the Applicants by this Application is claiming Rs. 13,60,275/- (

Rupees Thirteen Lac sixty thousand two hundred seventy Five
only) as a Compensation therefore accordingly he has affixed Court
fees of Rs.2720.55/- .

16) That the accident took place in the Jurisdiction of Kasara Police
Station , Tal- Shahpur, Dist. Thane, hence this Hon’ble courts
have jurisdiction to try, entertain and decide the application.

17) That the Applicants have not filed any other application for
compensation in any other Court .
18) The Applicants are intends to rely on the documents a list whereof is
annexed hereto .

19) In the above circumstances , the Applicants prays that :-

(a) The Opposite Party and the Insurer be ordered and decreed by an
award of this Hon’ble forum to pay to the Applicants jointly and severally the
sum of Rs. 13,60,275/- ( Rupees Thirteen Lac sixty thousand two hundred
seventy Five only) Under Workmens Compensation Act with 12% p.a.
interest due thereon from the date of this application .

(b) Any other and further reliefs that this Hon’ble Court may deem fit
and proper in the circumstances of the case be granted.

(V.C.Rathod)
Advocate for the Applicants Applicants

VERIFICATION

We, Smt. Hasnahara Begum Israil Sk & Ors, the Applicant

abovenamed, declare that the particulars given above have been verified by
me and they are true and correct to the best of my knowledge and belief and
that no claim in respect of the same accident has been filed or pending before
any other Forum.

Verified at Thane )

Dated this day of Dec., 2023 ) Applicants

(V.C. Rathod)
Advocate for the Applicants

IN THE COURT OF
COMMISSIONER FOR WORKMENS
COMPENSATION FOR THANE

W.C. A NO. OF 2023

Smt. Hasnahara Begum Israil Sk

& Ors.. ...Applicants

V/s
Saifulla Anwar Daras Shaikh
...Opp.Party

And
Magma HDI Gen. Co.Ltd ....Insurer

**********************************
**

APPLICATION FOR
COMPENSATION
************************************
Dated this day of Dec., 2023
 **************************************

V.C.Rathod & K.L.Rathod

Advocate for the Applicants

Ch. No. 44/45, 5th floor, Sucheta Niwas,

285, SBS Road, fort, Mumbai- 400 001
email. Vcrathod1989@gmail.com

Mo. 9892723058,,9209004814

**********************************

IN THE COURT OF COMMISSIONER FOR

EMPLOYEES’(WORKMENS) COMPENSATION FOR THANE
W.C. APPLICATION NO. OF 2023

Smt. Hasnahara Begum Israil Sk & Ors. …Applicants

V/s
Saifulla Anwar Daras Shaikh ....Opp. Party
And
Magma HDI Gen. Co.Ltd ....Insurer

I attest that above Photograph as of the Smt. Hasnahara Begum Israil Sk &
Ors., the Applicants
 ( K.L.Rathod )
Advocate for the Applicants

PHOTO CERTIFICATE

This is to certify that the affixed photograph hereinabove are true Photograph
of the Applicant Smt. Hasnahara Begum Israil Sk & Ors in the matter.

Dated this day of Dec., 2023

( K.L.Rathod )
Advocate for the Applicants

IN THE COURT OF COMMISSIONER FOR

EMPLOYEES’(WORKMENS) COMPENSATION FOR THANE
W.C. APPLICATION NO. OF 2023

Smt. Hasnahara Begum Israil Sk & Ors. …Applicants

V/s
Saifulla Anwar Daras Shaikh ....Opp. Party
And
Magma HDI Gen. Co.Ltd ....Insurer

LIST OF DOCUMENTS
Page Sr.No.

1) Certified copy of FIR ( 1 to 4)

2) Certified copy of Firyad ( 5 to 6 )
3) Certified copy of Purvani Jawab of Shahadev M. Khedkar (7)
4) Certified copy of Police Tipan of Saifula A. Shaikh ( 8 to 9 )
 5) Certified copy of Spot Panchanama ( 10
to 11)
6) Certified copy of Inquest Panchanama (12 to 13)
7) Certified copy of Cause of Death Certificate ( 14 )
8) Certified Copy of Insurance Policy ( 15 to 17)
9) Certified Copy of Driving License ( 18 to 19 )
10) Certified Copy of R C Book ( 20 )
11) Certified Copy of HGV Goods Permit ( 21 )
12) Certified Copy of Certificate of Fitness ( 22 )
13) Original Copy of Postal Receipt of Insurance & Owner ( 23 )
14) Copy of Demand Notice of Insurance & Owner (24 to 29)

Date:-
Place : Thane
( K.L.Rathod )
Advocate for the Applicants

IN THE COURT OF COMMISSIONER FOR

EMPLOYEES’(WORKMENS) COMPENSATION FOR THANE
W.C. APPLICATION NO. OF 2023

Smt. Hasnahara Begum Israil Sk & Ors. …Applicants

V/s
Saifulla Anwar Daras Shaikh ....Opp. Party
And
Magma HDI Gen. Co.Ltd ....Insurer

MEMO OF ADDRESS OF THE APPLICANTS

 Smt. Hasnahara Begum Israil Sk & Ors.
All the above Applicants are at present
R/at- at: 501 (1) Berugeram Kulutiya
Braddhaman, Sadipur, West Bengal

Place: Thane

Date:-

( K.L.Rathod)
Advocate for the Applicants

V.C.Rathod
Advocate for the Applicants
Ch. No. 44/45, 5th floor, Sucheta Niwas,
285,SBS Road, fort, Mumbai- 400001
email. Vcrathod1989@gmail.com
Mob.9892723058,,9209004814
*****************************
****
 IN THE COURT OF COMMISSIONER FOR
EMPLOYEES’(WORKMENS) COMPENSATION FOR THANE
W.C. APPLICATION NO. OF 2023
Smt. Hasnahara Begum Israil Sk & Ors. …Applicants
V/s
Saifulla Anwar Daras Shaikh ....Opp. Party
And
Magma HDI Gen. Co.Ltd ....Insurer
IN THE COURT OF COMMISSIONER FOR
EMPLOYEES’(WORKMENS) COMPENSATION FOR THANE
W.C. APPLICATION NO. OF 2023
Smt. Hasnahara Begum Israil Sk & Ors. …Applicants
V/s
Saifulla Anwar Daras Shaikh ....Opp. Party
And
Magma HDI Gen. Co.Ltd ....Insurer