I

FORM OF APPLICATION FOR COMPENSATION

(Rule-226)

IN

THE COURT Of THE MOTOR VEHICLE ACCIDENT CLAIM

TRIBUNAL, KATIHAR
V. Claim Case No - 05/2021
1. Rinki Devi W/o Late Ajay Kumar Ray aged about 22 yrs.
2.Chahat Kumari D/o Lt.Ajay Kumar Ray aged about 04 yrs.
3.Siksha Kumari D/o Do aged about 02 yrs.
4.Doli Kumari D/o Do aged about 09 months
5. Hira Devi W/o Shailendra Ray aged about 54 yrs. all resident of
Dumar Ward No-3 Po-Dumar Ps - Falka (P) Dist-Katihar- 854114.
Claimants.
Vs
1. The Branch Manager(Legall, The Bajaj Allianz General Insurance
Company Ltd. At- Ravi Commercial Complex, Nawaratan Hata, NH-
31 Upon IDBI Bank, Pumea-854301 (Insurer of M.Cycle)
12pt.
Humble claim petition on behalf of the
claimants U/S-166 M.V.Act.
Name and father's name of Ajay Kumar Ray S/o
the deceased Shalendra Ray
Full address of the deceased - At- Dumar Po - Dumar Ps-
- Falka(P) Dist- Katihar
Age of the deceased - 30 Yrs.
Occupation of the deceased- Labour
0\ •

kris Name and address of the

employer of the deceased
Not Applicable.
"E-sic
Monthly income of the 09,000/- 0 4 OCT
a'0-c,,
5
0-Dt°IH deceased
Does the person in respect of No.
'compensation is claimed pay
income tax.
8. F'laCe, date and time of accident NH-31, Near Khaira More 13;±'Falka
on 25.09.20
)
) . at about 10.00 pm
nW
9,./Nille and address of police Falka(P) Ps case No -328/20 dated
aigtion in whose jurisdiction 26.09.2020.

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accident took place or case

was registered.

10.Was the person in respect of Yes, The deceased was pillion on

compensation is claimed the offended vehicle BR-39AE/8188
travelling by vehicle involved in
accident.

11. If so, give the names of Kundan Ray had to go to his

places of starting of relation and hence he asked the
journey and its destination deceased to accompany him. Ajay
Kumar Ray, accompanied him as
pillion. After visiting, Both of them
were returning to their house.
Kundan was driving his motor cycle.

Nature of injury sustained. As per Post Mortem report.

Photostat copy of post mortem report
of the deceased /May Kr. Ray is attached
with this claim petition and the same may
be treated as part and parcel of the
claim petition.
Cause of death as opined by the doctor was
haemorrhagic shock caused by hard
running object.
Time elapse since death and PM was
within 24 hrs.
Name and address of Instant death. No treatment was
medical practitioner if any given. In the morning the claimant
attended the deceased and the Pothia Police brought the
deceased to Sadar hospital Katihar
where Dr. S.M. Thakur, M.0, Sadar
Hospital Katihar conducted pm on the
dead on 26.09.20.
Period of treatment and No treatment. No expenditure
expenditure incurred thereon.
Registration number and type 1. BR-11F/ 2182 (Truck)
of vehicle involved in accident. 2.BR-39AE/8188(M.Cycle)
Name and address of the 1. Kundan Ray S/o Krishna Dev Ray
owner of the vehicle. (Since Deceased) At- Dumar Raytola
Po-Dumar Ps- Falka(P) Dist-Katihar.
2. Name and address of the
-1- -7% truck owner and insurer is
not known to the claimant.

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49
:
Name and address of the 1. The Bajajlianz General Insurance
Insurance Company Company Ltd. At- Rat Commercial
Complex Nawratan Hata NH-31 Upon
IDBI Bank, Purnea-854301
Policy No-OG-21-2249-1826-00000285
w. e. f- 27. 06.2020 to 26 06. 2025.
Has any claim been lodged Yes. The claimant made oral claim
with owner/insurer. If so with to the father of owner of motor cycle
what result. but in vain.
Name and address of the Rinki Devi W/o Lt. Ajay Kumar Ray
Claimants. At-Dumar Po -Dumar Ps- Falka (P)
Dist- Katihar.
Relationship with the deceased Wife-Husband.
Title to the property of the The deceased was a young hale,
deceased- hearty and stout bodied boy. He
used to work hard to fulfil the necessity of
his family. He was the hope of his family.
Save and accept labour work he has no other
source of income but due to his sudden
demise, life of the claimant has been
paralysed, shattered and now the claimants
are suffering from mental agony, pain,
shock and financial stringency
Amount of compensation Compensation-Rs. 18,36,000/-
claimed- (multiplier-17)
The amount of compensation so
arrived at in the case of fatal
accident claims shall be reduced
by 1/4 in consideration of the
expenses which the victim would
have incurred towards maintaining
himself had he been alive. - Rs.04,59,000/-
Net Compensation Rs.13,77,000/-
Future Prospect Rs. 05,50,800/-
Conventional Head. Rs. 70,000/-
Total Compensation Rs.19,97,800/-
(Ninteen Lacks Ninty Seven Thousand
Eignt Hundred) only.
Any other information- (i) The deceased was a young boy.
that may be necessary He was hale, hearty and stout
and helpful in disposal bodied.
of the claim.
(ii) On 25.09.20 the deceased and his friend Kundan Ray
ati \*Ttir , Page 3 of 4
 (Since Deceased), the owner of the offended motor cycle
started from Dumar because Kundan had to visit his relation.
Kundan asked the deceased to accompany him on assurance
they will return back after two hours. Both of them started.
Kundan was driving his motor cycle and the deceased was
pillion on the said motor cycle. As soon as they reached near
Khaira more at about 10.30pm, one truck was stationed by its
driver in the side of the road without any indicator or sign.
Kundan could not see the truck and hit the truck from back
In that accident the motor cycle owner and the deceased died
instantly. The Police came, prepared inquest and in the
morning send the dead body for post mortem at Sadar
Hospital, Katihar. On the written report of one ASI Vinay
Kumar Tiwari a crime report was lodged in Falka (9 vide FaIke
Ps Case No -328/20.
(iv)That loss of life is irreparable and no amount of compensation
can compensate the actual loss sustained to the claimants but
for the sake of compensation amount mentioned in para - 22
of the claim petition be awarded to the claimants with simple
interest at the rate of 10% per annum from the date of filing of
claim petition till realisation of the award.
(v)That cause of action of this case first time arose on 25.09.20
when accident took place and the reafter several times and the
same is within your honour's jurisdiction.
(vi) That the claimants are the only legal representative of the
deceased.
In view of the circumstances the claimants are in urgent need
of compensation u/ s 166 M. V. Act.

AFFIDAVIT AND VERIFICATION

I Rinki Devi W/o Late Ajay Kumar Ray aged 22 yrs.

resident of Dumar Ps- Falka(P) Dist- Katihar do hereby
solemnly affirm and declare that the particulars mentioned
in this claim petition are true and correct to the best of my
knowledge, belief and information.
Verified and signed on the th Jan. 2021 within
court premises, Katihar.

Identified by

Advocate/Katihar Deponent

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