1

IN THE COURT OF THE DISTRICT & SESSIONS JUDGE AT UDUPI

ADDITIONAL M.A.C.T. AT KUDNAPURA
M.V.C.No. /2019
Between:
Shilpashree(26 Years)
D/o.Sadahsiva Rao
R/o.Near NH.66, Mudukeri Petitioner
Kundapura Kasaba Village & Post
Kundapura Taluk
Udupi District-576201

AND

1. Colin Mednonsa (49 Years)

S/o.Paul Mendonsa
R/a. “Savli”, Kalloni Cross Road,
Opposite Vijaya Bank Thalluru
Thalluru Village& Post
Kundapura Taluk, Udupi Dt-576230 Respondents

2. United India Insurance Co. Ltd

Rep by its Present Branch Manager,
Branch Office, Kundapura Branch
Sri Laxmi Narasimha Complex
Opposite KSRTC Depot, NH.66
Vaderahobli Village, Kundapura Kasba
Post, Kundapura Taluk, UdupI Dt.,
Pin Code:576201

POLICY No.2405023116P110702239 Valid From 27/12/2016 to 26/12/2017

APPLICATION FILED UNDER SECTION 166 OF INDIAN
MOTOR VEHICLES ACT 1988 AND APPLICATION IN FORM
NO. 63 (RULE 232) OF THE KARNATAKA MOTOR VEHICLE
RULES 1989.
The petitioner above named begs to submit as follows:
I. I, Shilpashree, Aged 26 Years, permanent resident of above
address, do hereby apply for grant of compensation for
the injuries sustained by me, in a Motor Vehicle Accident.
II. Necessary particulars regarding the vehicles involved in
the accident are furnished herein below.
1. Name and father’s name of the Shilpashree (26 Yrs)
claimant
D/o.Sadashiva Rao
2. Full address of the person As detailed in the cause title
injured
3. Age of the person injured 26 years
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4. Occupation of the injured Lecturer

person Manipal Institute of Technology
Manipal, Udupi Tq& Dt
5. Name and Address of the Director/HR Dept Admin
Employer of the injured Manipal Institute of Technology
Manipal, Udupi Tq& Dt
6. Monthly income of the injured Rs.30,000/-
7. Does the person in respect of No
whom compensation is claimed
was paying income tax?
8. Place, Date, and time of the Near Shri Ganesh Oil Mill,
Accident NH.66, Kasba Village, Kundapura
Tq, Udupi Dt.,576201
Date:17/01/2017,Time:05.15PM
9. Brief particulars of the accident In detail in Para III (a)

10. Name and Address of the police Kundapura Traffic Police Station
station in whose jurisdiction, in Crime No.12/2017
the accident took place was
registered
11. Was the person in respect Yes
whom compensation claimed The petitioner Shilpashree was
travelling in the vehicle involved travelling as a pillion rider in the
in the accident?
Motor Cycle bearing Vehicle
If so give the name of place of
starting of journey and Reg.No.KA-20-EG-9568 ridden by
destination one Suraj.U and was travelling
from Kundapura Shasthri Circle
to Mudukeri of Kundapura Kasba
Village on NH.66 and both the
rider and pillion rider have worn
helmet and the rider of the said
motor cycle was riding the said
motor cycle in a slow and steady
manner by following all traffic
rules

12. Nature of injuries sustained, As detailed in the Wound

Continuing affect if any of the Certificate Enclosed
said injury, whether it caused
permanent disablement?

13. Name and Address of the 1)Dr.Balakrishna Shetty(Major)

Medical Officer who attended Consultant Surgeon
the injured Chinmayi Hospital Kundapura-
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576201

14. Period of treatment and The petitioner was shifted from

Expenditure incurred thereon the spot of the accident to the
Chinmayi Hospital Kundapura in
a hired vehicle and was admitted
therein as inpatient from
17/01/2017 to _____for about
___days and has already spent a
sum of Rs.5,80,000/- (Rupees
Five Lakhs Eighty Thousand
Only)towards the medical
expenses
15. Registration No,.& type of Passion Pro DRS Cast Motor
vehicle involved in the accident Cycle Bearing Vehicle Reg No.KA-
20-EA-7230
16. Name and address of the Owner 1st Respondent
of the vehicle
17. Name, Policy No. , Insurance 2nd Respondent
particulars and address of the POLICY No.2405023116P110702239
insurer of the vehicle? Valid From 27/12/2016 to
26/12/2017
18. Name and address of the Driver Ceon Mendonsa(21 Years)
of the Vehicle S/o.Colin Mendonsa
R/a. “Savli”, Kalloni Cross Road,
Opposite Vijaya Bank, Thalluru
Village& Post, Kundapura Taluk
Udupi Dt-576230
Mob:9538729208
19. Has any claim been lodged with No
the owner/insurer of the
vehicle?

20. Name and address of the As Detailed in the cause title

applicant? above
21. Relationship with the injured? Does not arise

22. Title to the property of the Does not arise

injured?

23. Amount of Compensation Rs.

Claimed? And Basis thereof
24. Whether the report from the
Police and the report from the
Registering Authority have
been?
If so to be annexed?
Report from the police is annexed
and report from the registering
authority not annexed as it is
not available at present and will
be produced during the trail of
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the case

25. Whether the affidavit from the Annexed

Applicant/Witness as per rule
232© are annexed?

26. Whether documents mentioned Annexed, as detailed in the

in Rule 232© are being documents
annexed?
Duly indexed?

27. Any other information that may

be necessary or helpful in the -
disposal of the claim?
III.
A) That on 17/01/2017 the petitioner was travelling as a
pillion rider in a motor cycle bearing Vehicle Reg.No.KA-
20-EG-9568 ridden by its rider by name Suraj.U and was
travelling from Kundapura Shastri Circle side to Thalluru
side on NH.66 to go to her house at Mudukeri of Kasba
Village and the rider of the said motor cycle i.e. Suraj.U
was riding the said motor cycle in a slow and steady
manner by following all traffic rules and both the rider
and pillion rider i.e. the petitioner have worn helmet and
when the said motor cycle reached a place Near Shri
Ganesh Oil Mill, NH.66 of Kasba Village, Kundapura Tq,
at that time another motor cycle bearing Vehicle
Reg.No.KA-20-EA-7230 belonging to the 1 st Respondent,
coming in the same direction as that of the petitioner i.e.
from Kundapura side to Thalluru side ridden by its rider
by name Ceon Mendonsa in a very high speed, rash and
negligent manner, violating all traffic rules , without
having any circumspection and vigil over the road traffic
came to the extreme left side and dashed against the
motor cycle in which the petitioner from the backside,
due to the said impact the rider of the said motor cycle
along with the bike and the pillion rider i.e. petitioner fell
down to the road nearby and sustained grievous injuries
as detailed in the wound certificate produced herewith.

B) That the accident occurred solely due to the high speed,

rash and negligent and careless riding of the rider of the
motor cycle bearing Vehicle Reg.No.KA-20-EA-7230
belonging to the 1st Respondent, who was riding the said
motor cycle in a high speed and in a very rash and
negligent, careless manner violating every traffic rules and
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without observing the traffic rules and without proper care

circumspection and vigil.

C) That the petitioner was immediately lifted to the

Chinmayi Hospital at Kundapura in a hired vehicle and
she was given first aid therein, and therein he was
admitted as an inpatient from 17/01/2017 and was
treated for the said injuries sustained by her in the said
accident , her wounds were cleaned, medicated and
bandaged and she was given various treatments and then
as suggested by the treated doctors therein she was
discharged from the said Chinmayi Hospital at Kundapura
and was shifted to KMC Hospital Manipal in a hired
vehicle and therein she was admitted as an inpatient and
she was undergone CT Scanning of the head for the head
injuries sustained by her in the said accident and she
underwent various surgeries and X-Rays for the fracture
injuries were taken and she was given various treatments
and various clinical evaluations were done for the said
injuries and she was given analgesic antibiotics, and she
underwent various surgeries and rod was implanted in her
_____ and then she was discharged from the said KMC
Hospital Manipal on_____, hence in overall the petitioner
was admitted for about
___days in both the above said hospitals and have taken
various treatments Thus, in all petitioner has spent sum
of Rs.5,80,000/-(Rupees Five Eighty Thousand Only)
towards medical expenses. And still she is under
treatment, and the doctors treated her have suggested her
to take constant outpatient treatment and review along
with x-ray and scanning checkups as well as the need
future treatment and surgeries. She may require more
than Rs.1,50,000/-(Rupees One Lakh Fifty Thousand
Only) for her future treatment and surgeries etc as
suggested by her treated doctors.

D) That the petitioner spent a sum of Rs.1,00,000/-

(Rupees One Lakh Only) towards nursing and
attendant charges and of Rs.1,00,000/-(Rupees One
Lakh Only) towards food and extra nourishment. That,
the petitioner also spent sum of Rs.90,000/-(Rupees
Ninety Thousand Only) towards conveyance charges.
E) That the petitioner was quite hale and healthy and
had a well built physique at the time of the
accident. And was aged 26 years. She was working as a
lecturer in___department of ___Manipal and due to the
said job she was earning more tha Rs.25,000/- income
per month. Due to the accidental injuries she could not
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able to attend perform and do her work and she had

stopped working there and has been terminated from the
said post from the said institution and the said accidental
injuries and the disablement caused from the same have
adversely effected her career and her career and the
income that she was augmenting due to the same has
been spoiled out. The accidental injuries resulted on the
mental anguish of greatly impaired general health
of the petitioner. The petitioner has undergone heavy
pain and sufferings. The injuries have taken away the
amenities of the petitioner. Due to the accidental injuries
the petitioner sustained permanent disablement. The
petitioner has lost prospective hopes in her career . Her
treatment is not yet completed. Thus on a prudent and
reasonable estimation the petitioner has sustained
general damages to the tune of Rs.48,00,000/- (Rupees
Forty Eight Lakhs only) inclusive of damages towards
pain and sufferings, loss of amenities of life, loss of
income, loss of future earnings, loss of future
expectations of life, etc.

IV. Therefore it is prayed that the 1 st respondent as the

owner and the 2nd respondent as the insurer of the motor
cycle bearing Vehicle Reg.No.KA-20-EA-7230, are liable
to pay jointly and severally a sum of Rs.58,20,000/-
(Rupees Fifty Eight Lakhs Twenty Thousand Only) towards
damages sustained by the petitioner along with
interest at the rate of 12% per annum from the
date of accident till realization.

V. Hence it is prayed that the Honorable Court may be

pleased to pass an award against the respondents for
the following relief’s.
1. Directing them to pay a sum of Rs. Rs.48,00,000/-
48,00,000/-(Rupees Forty Eight Lakhs
Only) towards the general damages.
2. Directing them to pay a sum of Rs. Rs.5,80,000/-
5,80,000/-(Rupees Five Lakhs Eighty
Thousand Only) towards medical
expenses
3. Directing them to pay a sum of Rs. 90,000/-
Rs.90,000/-(Rupees Ninety Thousand
Only) towards conveyance charges
4. Directing them to pay a sum of Rs. Rs. 2,00,000/-
1,00,000/-(Rupees One Lakh Only)
towards food and extra nourishment
& Rs. 1,00,000/-(Rupees One Lakh
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Only) towards nursing and attendants

charges
5. Directing them to pay a sum of Rs.1,50,000/-
Rs.1,50,000/-(Rupees One Lakh Fifty
Thousand Only) towards future
medical treatment charges

6. Directing them to pay interest over

the above sum at the rate of 12% p.a.
from the date of the accident till
realization & to pass such other
reliefs. Rs.58,20,000/-
Total

Place: Udupi
Date: - -2019 Advocate for the Petitioner Petitioner

I, the above named petitioner do hereby declare that

what is stated herein above are all true and correct to
the best of my knowledge, belief and information.

Place: Udupi
Date: -2019 Petitioner

VERIFICATION
Verified at Kundapura on this …… day of April 2019, that the
contents of the above application are true and correct to my
knowledge and belief.

Kundapura.
Date: - -2019 Petitioner
LIST OF DOCUMENTS FILED ON BEHALF OF PETITIONER
1. True copy of the FIR and complaint.
2. True Copy of the Charge Sheet of Final Report
3. True copy of the Spot mahazar.
4. True copy of the wound certificate
5. True copy of the IMV report.
6. True Copy of the Accident Information Report Register issued
by Kundapura Traffic Police Station in Cr.No.12/2017
7. Notarized copy of the Family Ration Card of the petitioner
8. Notarized copy of the Aadhaar Card & Epic of the petitioner
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Place: Udupi
Date: - -2019 Advocate for the Petitioner
IN THE COURT OF THE DISTRICT & SESSIONS JUDGE AT UDUPI
ADDITIONAL M.A.C.T. AT KUDNAPURA
M. V. C. No. /2019
Between :
Shilpashree } -------Petitioner
AND
Colin Mendonsa }
& another } ----- Respondents

AFFIDAVIT
I, Shilpashree, aged about 26 years, D/o.Sadashiva Rao,
residing Near NH.66, Mudukeri, Kasaba Village& Kundapura
Kasaba Post, Kundapura Taluk, Udupi Dt.,-576201, do hereby
solemnly affirm and oath as follows:
1) I say that I am the deponent herein and the guardian of
the petitioner in the above case

2) I say that, I have filed above petition against Respondents

for compensation of the injury sustained by me in a road
traffic accident.

3) I say that, averments made in the above petition are all true
and correct to the best of knowledge, belief and information.

4) I say that, I have not preferred any claim application or

petition preferred any compensation with regard to the
cause of action of my above said petition or road traffic
accident met by me as stated in my petition

5) I say that, I have duly instructed my counsel to prepare the

above petition and I have signed the same after due
verification and found to be in accordance with my
instructions.

6) I say that, facts stated herein above are all true and correct.

Place: Udupi
Dated: - -2019 DEPONENT
Identified By Me:-
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IN THE COURT OF THE DISTRICT & SESSIONS JUDGE AT UDUPI

ADDITIONAL M.A.C.T. AT KUDNAPURA
M. V. C. No. /2019
Between :
Shilpashree } -------Petitioner
AND
Colin Mendonsa }
& another } ----- Respondents
LIST OF DOCUMENTS FILED ON BEHALF OF PETITIONER
1. True copy of the FIR and complaint.
2. True Copy of the Charge Sheet of Final Report
3. True copy of the Spot mahazar.
4. True copy of the wound certificate
5. True copy of the IMV report.
6. True Copy of the Accident Information Report Register issued
by Kundapura Traffic Police Station in Cr.No.12/2017
7. Notarized copy of the Family Ration Card of the petitioner
8. Notarized copy of the Aadhaar Card of the petitioner

Place: Udupi
Date: - -2019 Advocate for the Petitioner
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IN THE COURT OF THE DISTRICT & SESSIONS JUDGE AT UDUPI

ADDITIONAL M.A.C.T. AT KUDNAPURA
M. V. C. No. /2019
Between :
Shilpashree } -------Petitioner
AND
Colin Mendonsa }
& another } ----- Respondents

PROCESS FEE MEMO/BATTA MEMO

It is submitted that;
The counsel for the Petitioner has paid the
process fee of Rs. 16-00 is herewith. That this
Honorable Court may be pleased to issue Notice to the
respondents through RPAD in the above case.

1. Colin Mednonsa (49 Years)

S/o.Paul Mendonsa
R/a. “Savli”, Kalloni Cross Road,
Opposite Vijaya Bank Thalluru……………………..8.00
Thalluru Village& Post
Kundapura Taluk, Udupi Dt-576230

2. United India Insurance Co.Ltd

Rep by its Present Branch Manager,
Branch Office, Kundapura Branch………………....8.00
Sri Laxmi Narasimha Complex
Opposite KSRTC Depot, NH.66
Vaderahobli Village, Kundapura Kasba
Post, Kundapura Taluk, UdupI Dt.,
Pin Code:576201

======
Total Rs. 16=00
======

Place: Udupi
Date: - -2019 Advocate for the Petitioner
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C.P.C.(100) I.A. NOTICE IN C.M.P.

In the Court of the M.A.C.T at Kundapura
M. V. C. No. /2019
Between :
Shilpashree } -------Petitioner
AND
Colin Mendonsa }
& another } ----- Respondents

To
R1,
Colin Mednonsa (49 Years)
S/o.Paul Mendonsa
R/a. “Savli”, Kalloni Cross Road,
Opposite Vijaya Bank Thalluru
Thalluru Village& Post
Kundapura Taluk, Udupi Dt-576230
Mobile No:9538729208

Whereas the above named...................................................has

made application to this court that …………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………

You are hereby warned to appear in this court in person or by a

pleader duly instructed, on the ………….day of …………20……..
At 11 O’ clock in the forenoon to show cause against the
application falling which the said application will be heard and
determined exparte.

Given under my hand and seal of the Court this ………………..

day of …………………………….. 2018.

(By order of the court)

Advocate for Petitioner Central Nazir

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C.P.C.(100) I.A. NOTICE IN C.M.P.

In the Court of the M.A.C.T at Kundapura
M. V. C. No. /2019
Between :
Shilpashree } -------Petitioner
AND
Colin Mendonsa }
& another } ----- Respondents
To
R2,
United India Insurance Co.Ltd
Rep by its Present Branch Manager,
Branch Office, Kundapura Branch
Sri Laxmi Narasimha Complex
Opposite KSRTC Depot, NH.66
Vaderahobli Village, Kundapura Kasba
Post, Kundapura Taluk, UdupI Dt.,
Pin Code:576201

Whereas the above named...................................................has

made application to this court that …………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………

You are hereby warned to appear in this court in person or by a

pleader duly instructed, on the ………….day of …………20……..
At 11 O’ clock in the forenoon to show cause against the
application falling which the said application will be heard and
determined exparte.

Given under my hand and seal of the Court this ………………..

day of …………………………….. 2018.

(By order of the court)

Advocate for Petitioner Central Nazir

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IN THE COURT OF THE DISTRICT & SESSIONS

JUDGE AT UDUPI AND ADDL. M.A.C.T AT
KUNDAPURA
M. V. C. No. /2019
Between :
Shilpashree } -------Petitioner
AND
Colin Mendonsa }
& another } ----- Respondents
INDEX
Sl.N Description Pages C.F.
o Paid
1) Petition with verification Rs.10/-

2) Affidavith

3) Vakalathnama

4) Process Fee Memo/Batta Memo Rs.16/-

5) List Of Documents(Originals)

6) Copy of the Petition(2 sets)

7) List Of Documents(True Copy)

8) True Copy of the Petition

TOTAL
Rs.26/-

Place: Kundapura
Date: - -2019
Advocate for the Petitioner
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