IN THE COURT OF HON’BLE SH.

AMIT BANSAL, JUDGE (MACT)

ROHINI COURT, ROHINI DELHI

IN THE MATTER OF: -

1. PRIYANKA MALIK
(Widow of Deceased) Late Sh. Virender Singh Malik

2. AKSHAY MALIK
S/o Late sh. Virender Singh Malik
(through his mother- natural guardian)

3. SMT. RATNI DEVI

W/o Late sh. sadhu Ram Malik
(mother of late sh. Virender Singh Malik

All Petitioners are R/o B1-52A, West Shalimar Bagh, Delhi 110088
…PETITIONERS

VERSUS

1. SHUBHAM AGARWAL
S/o Sh. Manoj Agarwal

2. MANOJ AGARWAL
S/o Sh Ram Niwas Agarwal
Both R/o X-501, Siddhartha Apartment. MP Enclave, Pitampura, Delhi
110034
3. TATA AIG GENERAL INSURANCE CO LTD.
Connaught Place, Lotus Tower, 1st Floor,
New Delhi- 110025 … RESPONDENTS
THE UNDERSIGNED MAKES THIS APPLICATION FOR GRANT OF
COMPENSATION AS PER THE PROVISIONS OF THE MOTER
VEHICLE ACT, 1988 ON THE BASIS OF SECTION 166 AND 140 OF
MOTER VEHICLE ACT ON FOLLOWING FACTS AND
INFORMATION

PART- 1

Sir,

1. Name & Father’s Name of Late Sh. Virender Singh Malik

S/o Late Sh. Sadhu Ram Malik
the person Injured/dead

(Husband’s Name in

the case of married women &

Widow

2 Full address of the person B1-52A, West Shalimar Bagh,

Delhi -110088
injured/dead

3 Age of the person injured/ 33 years (DOB: - 09/03/1986)

dead

4 Occupation of the person Constable in Delhi Police

injured/ dead

5 Name & address of the Delhi Police (PHQ, ITO),

New Delhi 110001
employer of the injured/dead

6 Monthly income of the Rs. 43221/- PM

person injured/dead
7 Does the person in respect of Yes- Rs/ - ___________???

whom compensation is

claimed pay income Tax? If

so, state the amount of the

Income Tax (To be

supported by documents)

8 Place, date and time of Metro pillar No. 322, Road No- 41,
29/05/2018 (at 11:45 PM)
accident

9 Brief Particulars of the As per DAR Report

accident

10 Name & Address of Police Subhas Place Police Station,

Netaji Subhash Place Complex
Station in whose Jurisdiction Pitampura, Delhi - 110034

Accident took place or was

registered

11 Was the person in respect of No

whom compensation is

claimed travelling by the

vehicle involved in the

accident? If so, give the

name & Place of starting the

journey and destination

12 Nature of injuries sustained (Fatal- DIED ON THE SPOT)

and disablement, if any,

caused

13 Name & Address of Medical Bhagwan Mahavir Hospital

Pitampura, Delhi -110034
officer/Practioner if any,

who attainded on the injuries

14 Period of treatment and N.A. (Died on the spot)

expenditure if any incurred

15 Registration No. & Type of DL-8CL-5158 (VOLKHSWAGON)

Vehicle Involved in the

accident

16 Name & Address of the Respondent No-2

owner of the Vehicle

17 Name & Address of the Respondent No-1

driver of the Vehicle

18 Name & Address of the Respondent No-3

Insurer of the vehicle

19 Has any claim been lodged No

with the owner/insurer? If

so, with what result

20 Name & Address of the As Mentioned in application

applicants
 21 Relationship with the Wife, Son & Widow Mother

deceased/ injured

22 Title of the property of the N.A.

deceased/ injured

23 Amount of compensation Rs. -___________??

claimed and basis thereof

24 Whether the reports from the As Per DAR filed by the concerned
Police.
police and the Registering

Authority have been

obtained in form A & D (if

so, to be annexed)

25 Whether affidavit of the Yes

applicant and witnesses as

per rule 8 are annexed (give

details)

26 Whether documents Yes, as per DAR Report filed by the

concerned police
mentioned in rule 8 are being

annexed duly indexed (give

details)

27. Any other information that may be necessary and helpful in the disposal the

case: -
 a) That the deceased was working as constable in Delhi Police and was
the only bread earner of the family consisting of wife, son & aged
widow mother.
b) That on 29/05/2018 at about 11:45 PM the deceased was waiting for
the signal at metro pillar No. 322, Road No 31 on his scooty bearing
No. DL-8BW-0962 (Honda Activa) suddenly a Volkswagen bearing
registration No. DL-8CL-5158 which was driven in a rash and
negligent manner by the respondent No. 1 hit the scooty and due to
the heavy impact of the hit by Volkswagen the deceased fallen on
the bonnet which was observed by ASI Radhey Shyam No-
1523/PCR, who immediately arrived at the place of accident and the
said ASI took the deceased to Bhagwan Mahavir Hospital, for
admission and on arrival at Bhagwan Mahavir Hospital declared the
deceased as “BROUGHT DEAD”. Moreover, as per the PM report,
the doctor in his opinion has stated that, “CAUSE OF DEATH IN
THIS CASE IS CRANIO CEREBRAL INJURIES CAUSED
BY BLUNT FORCE/SURFACE IMPACT WHICH COULD
BE POSSIBLE IN ALLEGED CIRCUMSTANCE”
c) It would be pertinent to mention here that in this case the Respondent
No- 1is driver of the offending vehicle, Respondent No-2 is Owner
of the offending vehicle, Respondent No- 3 is insurer of the
offending vehicle, hence all the three respondent are jointly and
severally responsible for the compensation which is to be paid to the
petitioner(s)
PART-II

28 Amount of compensation Rs.

claimed as interim award

29 Reasons for claim of interim as mentioned in the application

award that the deceased was the only

bread earning member of the

family consisting of wife, son

and widow aged mother and

after the death of the deceased

there is no helping hand to

support the family left behind

 the deceased. Hence request

for interim award may please

be considered on humanitarian

ground and in the interest of

the Justice

30 Whether documents As per DAR report filed by

mentioned in rule (4) and the concerned police.

sub rule (5) of rule 20 have

been annexed (give details)

31 Prayer :

It is therefore respectfully prayed that this Hon’ble Court may be pleased

to pass an award of Rs. _________________ along with the interest of

10% per annum under the facts and circumstances of the case and in the

interest of Justice.

Petitioners

Through

(Multan Singh & Balwan Singh)

Advocates
Ch. No.129, Patiala House Court
New Delhi-110001
Mobile No:- 9811887155
VERIFICATION

Verified at Delhi on this _____ day of feb 2019, that the contents of the above

application are true and correct to our knowledge and belief.

Petitioners
 IN THE COURT OF HON’BLE SH. AMIT BANSAL, JUDGE (MACT)

ROHINI COURT, ROHINI DELHI

IN THE MATTER OF: -

PRIYANKA MALIK & ORS …PETITIONERS

VERSUS

SHUBHAM AGARWAL & ORS … RESPONDENTS

AFFIDAVIT

I, Priyanka Malik W/o Late Sh. Virender Singh Malik, Aged About 31 years,
R/o B1-52A, Pitampura, Delhi- 110088, do hereby solemnly affirm and declare
as under:-
1. That I am one of the petitioners in the above noted case hence, am well
conversant with the facts of the case hence am competent to swear this
affidavit.
2. That the statements of facts contained in the application are true to the best
of my knowledge and belief.
3. That I have filed no other similar petition with regard to the same cause of
action anywhere in India except the present claim petition.
4. That I rely upon the DAR filed by the concerned police which is already on
record of the Hon’ble Court.
______.

Deponent
Delhi
Date :-

Verification: -

Verified at Delhi on this _____ day of feb 2019 that the contents of the
above affidavit are true to my knowledge and belief.

Deponent