2o2t-

I.{\N qo l- o o5 1 ? 3 -

PMHNG0l0{EZ3to22_l_1
Mi-*

tl
llo.3
DISTRICtrA}{D ffiiI(}NS O(l[,f,tr HAC?T]R,

INTI{B CQURT Or K &&&c

Sht{. D.

It A"CT. eOUm I{()& Nqn$ (t ttan* N.gIxtB

ST'MIfiONSTOAPMARIN M&C.?J4nnw2
EMSON RaJrndra Ulmdrto RqId.rVs Ih MfiriEg, ICICI
L@bad Gcn. rr& Co.Ltd.
(o. s, R.3.) NEXTIIAIE: Itl-lG20Zz

Tq
TheMmsgeri ICICI Lmbard Gen Ins. Co. Ltd.
5& lbor, Iand Madq P.n. 5 ard 6, uardha ruart Rarndmpee, Nag1re

whees Rrtndra ukundrao Rirnrhr has itrsthsed a $dt egginst you fm you aIE hemby

sumrored to appear in d1j3 Corrr1 in pcrson on the l&ll)-Zt2il 8t 11:00 o'do& tn thc ionnooa, O
answer fte claim; and Srou are dirrected to piroihrce oo that day all fu documerts upon which yot inmd
o rcly in srpport of your tletence.

Tbke rotice thar, in defuult of your apearance of the day before mentione4 the suit wlll be

head and determined in yorr absence. VI-

Givm rmder my hard ard the seal of the court, this l4'u1'2tzz Begistrar (rurll|
ata"c.ft&firko.a
Segpun
Bm No. SIS& Copy d aplldon uA 106 M VAtt Eltlrith.

Th pocess is systcm genuated and ranmited in smred a such physrcsl

sigDatne M ryplied.
e!: -- -'# --_/
\
BEFORE TIIE or' THE MO RA CCIDENT
CLAIM TRIB NAGPI]R.

Claim Petition No. t2022

PETITIOITTER: Rajendra S/o Ukundrao Rajurkar

Aged- 41 yrs., Occ- Brt' Work,
R/o. Ward No. 01, Saoner Road, Near
Hanuman Mandir, At Bwujwada, PO-
Malegaon, Dist NagPur-44l 107
Through Power of AttomeY
Dhirendra S/o Vasantrao \iladke
Aged- 36 yrs., Occ- Pvt. Work,
R"/o. Ward No. 01, PiPla Dag bangla,
Pipla (da-B), NagPur-44l I 13.

-: YERSUS:-

RES POND ENTS: 1.r mbard General Ins. Co. Ltd.

uCh its Manager
5s Floor Land Mark Plot No. 5 & 6
Wardha road RamdasPeth, NagPur

2 Mr. Mohammad Rahim Sajjad

Aged about Major, Occ:- Owner
R/o p. No. 120, Eidgah Road, Jaffar Nagar'
Near Eiddgah Ground, Katol Road,
Nagpur- 440013.

R OF COMPE NSATION ER
lFrr-,r ATI N ED
SECTION 166 () THE MOTOR VEIII CLE ACT AS
ACD.
The petition most respectfrrllY submit as under and thus claim of
compensation on ount ofinjury sustained to Rajendra S/o Ukundrao
Rajurkar, who sustained mJury in vehicular accident on Dt.
0410412022 at l4z hours. The necess ary particulars in resPect of the
person injured, the ehicle etc., are given below:-

1. Name and father s name of the Person injure :- Rajendra S/o

Ukundrao Rajurkar
2. Full address of person injured :- As Above
3. Age of the pers injured :- 41 Years
 -7-

4.Occupation of the person irIrjured Service

S.Name and address of the E]mployer Plasto Tanks &
of the injured, if any Pipes Pvt. Ltd.

6.Monthly income of the on injured. 15,000/- pm.

7.Does the person in respectpf whom

compensation is claimed, priay income-tax?
(to be supported by documfntary evidence)

8.Place, date and time of accifient Near Plasto Company

Central MIDC Road,
Nagpur.
On2010412022
At 14:00 hrs.

9.Name and address of Pol ce Station in Police Station,

whose jurisdiction the ac took place MIDC, Nagpur.
or was registered.
10. Was the person in re ofwhom The petitioner was
compensati on is claimed, eling by vehicle riding the Motor
proceeding by involve in accident? Cycle No.
if so, give the names ofp of starting Mrr-35-W-7238
joumey and destination.

ll.Nature if injuries ed and continuing Grievous injury

effect if any, of the i njury.

12. Name and address of Medical Officer/ Lata Mangeshkar

Practitioner, if any who ded on the dead. Ilospital Nagpur.

l3Jeriod of treatnent an expenditure ifany, Still Continue.

Incurred thereon (to be rted by docum-
- entry evidence).

l4.Registration number type ofthe vehicle Maruti Car No.

Involved in accident. MH-31-FR-1500

l5.Name and address of (e owner of the The respondent

vehicle. No.2
 -3-
'16. Name, policY n 9f' insurance particulars :-The ICICI Lombard
and address ofthe ofvehicle. Gen. Insurance
Policy No.3001/OMI-
10294086/00/000.
Period of PolicY
Froml4l09l202l
Up to 1310912024
17.Has any claim een lodged with the owner/ :- No
insurance? It so what result.
l8.Name and ss ofthe applicant As above.
lg.RelationshiP w injured. Self
20. Amount of the compensation claimed
Rs. 1,00,000/-
21. T\at, the Peti oners have not filed the petition in anY court oflndia
except the Present tion.
22.T\aqrhe accl took place 0410412022 at I4z00 hours. The said
accident occurred In front of Near Plasto ComPa ny Central
MIDC
Road. The no. 2 is the registered owner of the said
holding
Oftending Maruti Car. The driver of the offending vehicle was
valid and effecti driving license at the time of accident' The said
offending vehicle s insured with resPondent no. l.
23. That, on Dt. 022, the petiti oner was riding the MotorcYcle
No. MH-35-W-7 3 8, at tlat time offending Maruti Car No. MII-31-
e in high speed with rash and negligent manner
and
FR-1500 was
therefore the driv of offending Maruti Car had lost control over
his
vehicle and gave a forcible dash to fte motorcycle of the Petitioner,
resulting to whi the p etitioner had sustained grievous injury i'e'
Fracture Right Leg, Head Injury. After the said accident
the
petitioner was diately admitted into Lata Mangeshkar HosPital'
Nagpur, where has treated and oP erated the said injury. But the
above said in could not be cured and therefore, the petitioner is
suffering from ent disablement. The petitioner has spent the
expenses near of Rs.2,50,000/-towards his medical treatnent and
still the treatnent continue.

24. That, the d accident is occurred due to rash and negligent

marurer of driver f offending Maruti Car. Therefore, Police
Station-
MIDC Nagpur registered an offence UIS- 279 , 33 8 of IPC; vide
Crime No.318/2 22 against the driver of offending Maruti Car.
 /-;
-4-

25. A)_Becunigry_DslqeCes: That, at the time of accident, the petitioner

was aged about 4l years he was doing the service in Plasto Tank &
Pipes hrt. Ltd and getting income of Rs. 15,000/- per annum. But
due to the said accident peti oner unable to do the said work properly.
The petitioner affected the activities. The working capacity of
petitioner became reduced therefore, the petitioner is entitled for
future loss of eaming.
The peti tioner has s of Rs. 2,50,000/- on the medical expenses
and treatment is going on petitioner is required to spend the amount
on future treafrnent. The tioner also spent the expenses on auto
charges, attendance charges special diet.
B) Non Pecunia Dam :-That due to the sudden accident the life
of the petitioner has been e cted and he is not in a position to do his
daily routine work properly The petitioner has grievously injured in an
accident. The said injury co dn't be cured and the petitioner will suf[er
from the said accidental ury till his death and the petitioner has
affected on his body, also m tal and monetary losses. The petitioner has
affected his longevity and great impact on health of the petitioner.
The future life ofthe petitio er has been affected.
Therefore, the petiti is entitled for the damages under the head
of Pecuniary non& ary damages. Therefore, the claim of
compensation is calculated under:-
A.Pecuniary Damages:-
i) Medical Expenses till t and future :-Rs. 5,001000/-
ii) Loss of earning &future :-Rs. 10,00,000/-
iii) Damages towards trave expenses
Maidservant, Special diet :-Rs. 1,00,000/-
B. Non-Pecuniary Dama s
i) Damages for mental and cal Shock,
Pain and suffering :-Rs. 1,00,000/-
ii) Damages for Loss of nities of life :-Rs. 1,00,000/-
iii) Damages for loss of exp on of life i.e.,
(On account ofinjury th normal longevity
ofthe person is shortened) :- Rs. 1,00,000/-
iv) Damages for inconveru ce, hardship,
Discomfort, di sappointm nt, frustration and
Mental stress. :-Rs. 1 , 00 000/-

Total Claim of compensatipn :-Rs.20,00,000/-

\- -5-
Thus the claim of compensation is derived of Rs. 20,00'000/-. But
the petitioner their claim till Rs. 1,00,000/-.

26.T\at, the petiti er shall enhance their claim of 166 of M.V. Act
after getting the c pensation u/s 140 of M.V.Act' The petitioners have
not position to pay the court fees stamp at this stage.
27.Tltat,the peti er has filed the petition in prescribed form and the
Petitioner has file documents as per list and reserved right to file the
more, as when d and also reserved right to make an amendment
in petition after fil the Written-Statement.

PRAYER:. is therefore, prayed that this Hon'ble court be

pleased to grant th relief as under:-

1. The responde are liable to pay the compensation of Rs.1,00,000 /-

with interest at th rate of Rs. l2Yop.a. from the date of accident till its
realization the am

2. The cost of petition saddle upon the respondents.

3. Any other reli f, which deem fit under any circumstance be also
granted to the peti oner,

Nagpur.
C.F.P Petitioner.
Dated: -1310612 2
"funer
s olemn Alfirmation
I, Dhirendra S/o Vasantrao Wadke, Aged- 36 yrs., Occ- Pvt.
Work, R./o. Ward . 01, Pipla Dag bangla Pipla (da-B), Nagpur-
441113., do here state and takes an oath and solemnly declared the
Contents of the ab ve paras has been drafted by my counsel as per my
instruction and he explained to me in my vemacular and is found to
be true and correct my personal knowledge and belief'

Hence verifi and signed atNagpur on 13ft day of 1wre,2022.

Ikn ow the De pon nt personally.

Deponent.

. S. Mirac ocate
.J '!'!.
 .1
,- E,'r{ Tg' DaC* N "

( ftqq akiFi) rru (t) (ii) (c) rtr (r,e) (iv)

i$
drcn sIrTEIrf,I iIFtrqI 3rAIr,6I

l. ffisfficra rnr$. qrr tgi.

o'
e. stlqEl 6-qr(]D.
€.sr.d./orq{q
qr6go 3IrL 6
o-mq
7l .tL s*{ }tt, fis-Ae'l }r'cil.

i. oqqrdrfi drtq +d o ftqs e4 ) t+; oD ,fle, oa ar<V.

olt laozz
r. rrdZfyb tn j E)" js"r $; *rl 4o
\ F {,+< 9< dtl 4
t. rorer,zft-er
iorrd 3Trd
qt qqr€nalrf,
dlt q-qrsrqri Trq
ri\ u'"\r rz1 U,j) ,nr 1"/i.
q. iTTE;IEIT iF.qTO q CiDT( gt
&. (tn sr F(. l5-oo.
\\
E. qrFI qrf,tr'ri ;IFI cI rtRTt
qrfirqr dqRrd srE-{ qrdfruqrqr
qrqm ttmqr orql+qrqr q-cr
tl Ar\& <-
q4 3_y
N4c- .nrn S.)f+a
,rtY(^ '"( ('
"M , at"s{
<, sIrIEIrfl grntrr drudq srs&flr
qrEq qa-orA flq qdT + (-\
\ d\Q' t[^. o+tr-rll C dlT .s-8

+ gr flr f,ridg qEFIrqI i,ql

oll (rt)t c al. LrA fi
fl}{ {
"' *,N
,t:'ilt,
sFIEItd
Hr siq-+A :nd qRrT
T c:IcT ftrdr ) d.r<ni
fdqr o[Sd
6. DfiJ { -rr"fli.
rc. frsn fr-frS 6ci6lfrqr cqrura
qte o. s nqr qid-$-ff Ardr
w 8oo /o / nr - ro z-/lo96, f */*,
t

g:. srorO qr6{rn Ers-fi-( ft-flrqr

!G,t, 14lo7 f aazt # ta/of/au*,,
Lt4'it-
6qfo sTrFr ftqr erFr qcr rro ,.
gq. dffi o,rffi q,6< -S4 tt\{(<l l{(-
"rt
H-o
qEq)
Frqq q.6 ..,IFT.
E3{. qs-€I.€.
ilt.€.qr{r,{{ dlr(
 ,}
f -r-.
\
\ JI,

,-$l N,c.R.a (!-{.dl.sR.fl)

/ 6 \i-iii
>. C:
Lr.F.-t ((6tf,d sr,tqq si{ - 9l
* I
l;
* Errl) El RS-T-INLO_R Maro+nnaqBr
L- /, (Under Sectton 154 Cr.p.C.)
9prq (f+s 3{EErs
(4,Rrr lq8 cisff$ nbqr {ffdr}
r. Distrlct (F-6r): E
'rsI !r6q p.s.(ortr: cq.s(.S.fl. velr (q{l: zozz
FIR No.(neH w{r iE.): 0269 Date and Time of FtR
2.
{[. B. R-ci6 3[fq ]dl: 04/04/2022 23:31 4i
S.No. (cr.i5.) Acts (qQftqq)
Settions (iEFrc)
1' rrrtfrq <s iiFdr q.r,o :ro\
2 mifia rs iikr ter,o {{c
g qr.tlh rg fiBfl s(qo
t lte
3. (al Occurrence of offence (far{ e-g 1;
r. rmi
Day(R-fi):r Date From tft_<i* qfqOl O4tO4l2O22
Time period Date To ( ffio vfol:
(ETfi4dt): o4lo4no22
Time From lf&nq113 14:00 ri
(b) rnrormation recerved at p.s. ({rBd
-#"#lH;}: to:oo +i '
Date (ft-I'?; lt o4lo4l1ozz Time (+61: u:oo TS
(c) General Diary Reference
fttfirqet €"t
Entry No. (+s F,l: 076 Dat€ & Ttme (ga;+ BfiFr +6t: oa/04/2022 ?3:31 q-$

4. Type of lnformafion (qrBfifl non): +d

5. Place of Occurrence (treir$etEt: i

L(El Dlrectlon and dtstance from p.s.(+dffl Ertrrncrw Em q aial): g-w, f ft4
BeatNo'(freF}r
{b)Address (rdrt: wdihr{-fi6+*r,Mroc rts il.Er .
(c) ln case. outside the limit of thls Police Station, then (qr ffi ottrqrql FdhGr 3rtr r€t!
Name of P,s,t+#t{ orEqri Tr4}:
Dlstrict(state) (R-cEr({riat}3

6. Gomplalnant / lnformant (E-fiFER/cIffi eDrEI):

(rlName(: iI):
'It€ tfi'(
qi4G Eq' 21 a{
(bt Father's/Husband's ]l ame(a-*a / qd i
l1lHt{es): qnf,
tct EillE/vear or Blrth (ff'I{r+c/s{): 2ool
(dl Nationality
(Gl ulD No. (g.3n{r.sl. F.)l
lO Passport No.(crq'r m'.t: Dateiof lssu€ (E r4 aTfis):

Place of tssue (FFqrt lloM):

*,$#,&$.,*"#tri1#H.JEF[1f :Afi$'r1]?[nt?[J{*:HH$T'*'
c-fin) ltt Nuinber tdtror*m ffi
s.No.(3I. rd rype (sfdsrdrEr

1
 ,i

,i N.C.R.B (Sj.S
slNo.(:r. td Type (0ililsr.{ilt ' j r.l. r.-l tr6-E-a ar{ru $tq
1
yiFR)
ld Number ( .th"** Fqr6) -

(h)
Address (qi l:
5.No
Typ e (Teqfsl dd ress (Ifr[]
if.
1
Itc{ w fiar m qmi!,8 flgr,qc . d.rft ,,qrgv s6r, qpq,q6-6
2
i,,rn"* ft,Rr crr .i[dr m fiEh ,G ilqgr .w.
(i) occupation (qtrcrfl S.dl., r,rgt rrer,mnrq, rnro
:
(i) phone number
(trlc i.).
7. Details of known/su Mobile (qtqrfo t.) : 9t-7057832904
oirt+qr sPected/unknown
tiW qrn): . accused tvith fu particu rs (qrfro srs+@r nirA6Tqdatst
S.No. Name (Trq)
(3r.ft.) Alias (q6;nd)
Relative,sName ipre sent Address (a-dvn
1
fr, H
(ilil{rffiirq} v-a4.
3 1 F R- I 5 00 qI iTETq'
8. Reasons
I .\,7 .,iq5{
for delay in rnr,rsmg,rya6
6lMld rdil{rdl s,RD}l .reporting by the complaina nt/informant
9, Particulats ton-qr6-€r ilfirq
of properties of ln
S,No, terest (iiidta qrf,r+sr
dcahfl!
(q.ar.) f#95;.'"r"", ?rop€ rty Ty pe
( {rdT{I ITiDR' Desciipiib isfiI
1o Total value
of.p rope rtv ( h nsl- Vitueiiri'Fi7:r - -
sf,,q tF4 ls. qta) l -ttr},{trr t+er-crdrtt
,(Fq (r. cEtit'
tt / u,D. case No.. ir any (s@(d
H:#:,lHii:t ccri'/ s6..Frrd
rs{
to lulDB Number (g.qrq.s.
*:l''
I

F. 705 7832904
t
ftft ,ri.fr.*q.* mlqrni
o,rd1 il. o4/0
ri$r ir-gr6t qats 32 q{4t202
qifl
I
RS tf,l- 40
s00 t
q iili

2
I

N,C.R.B (r+.cfl.3fl?.d,
,.l,F,-l ((A!lrl iFifi $iq - 1l
I3,Action Slnce the above information reveals tommission of offen(e(s, u/s as mention€d at
(t'-ff| onar{, srq m.? qtA r{< irt-eur ird'IFil.) {0'd otarirar.ru{ olc{q Etgafit,l
(r) Registered the €ase and took up the or tfthul)
investisation: (cFfl{ dhft-i :nFr aqnrr} atq
srd i-a-il:
(2) Dlrected (Name of l.o,l (aqnt ultfiT-qrt {ra): viiay Santoshrao Gaikv/ad
Rank (rr<): Asst. 5l (Assistant 5ub-lnspector)
gfuF|l R.dl or (6.qr,
No.(f')3 PoBN47272 to take uP the l'}ve'tigation (aI irql{ 6'rE.{Iri
(3) Befused investigation due to {wt onErg* o16 ,a*19 6n ktn):

or (cqr tFnrql* vr{r org'qrfi r6n EEfl)

(4t Transferred to P.s'(g€ grrtfi-i qrdft-flI ors"-qrfl +qr ilds alEqri ar4t:

District (ffra-{I):
on point of ,urisdiction tol ffo-on t onc E€''kft-dl '
F.r.R. read over to.the comptatnant / lnrormant,ahmitt"o*HffiSfiI$; # #*$:*X'
$#.e*h.ggm"*,"1ff"m*m;',ilhlfl H+*""-E*.,
B.o.A.c.(srR. d.( 'dJ I

aot / I a in
*' ;:fl }s'#,;f, sP
iiFJ#"1?ll*#,H1i#ffif
i
' (qr'nEr'Ira
15.Date and time oI dlspatch to the court
qrd{"-qrfl il{}s s +6r:

signatu officer in c harge, Police

Statlon 1oro] ccrff 3{Frol-{rfl
rkar
Name (;IRl
Rank .dlr
No.({{
€r

Fq.ffi
ft.€;ffi;*o.f'o'
 I

I
t+. w
.ri ,'2

l
,|

i
"'i i';.,:1;.,;,,-r,. "
t-
t-
.'
;

:i1 NJ
l
I

I
 Form : ll

@#rF4' CRIME DETAILS FORM

T€raII a!frIdl"r TT{./!-fiRerd

1. Sta'te .P S. fn$Sc-FlFuProceeding/G D. 9..vear .2L Date _q.:4:.2:L
{ral ft-er qffiseYrc qRdqfi F.rrdrffi 6qis q{ fi{iF

,' 2. ryt^arld
ssctions ; ...*?-q 33..ts &L:1..I.P.e-,
srEFEiq t E-flt ,

3r The Plaoe of Odcunence shorJtn by:

qEit E?irt4 ?fqf4tnqrn :
qTa.(qv
H''{ +q- b'ts ffi/rfriqE:
Father's/Husband's e
..er D'I'
qfir Swr ew aiamr cT.
A:ddrdss
:
:
B. nruy;
4. fYPE oF CRIME (AI iicuding M. o. crime) 'stMtdi'
Tflrqr tbR (C€rqr sd Egfrre),
(i) Majot
qer{ 1fr{
Head
, ,frr (ii) Classification of
,qn
Majoir head (Mi
efifqr f{qrrr
Head) : ...

(ffi) tvtethod (s)

16
1. .. . ar.pr..*rrg9-dm: @--. z *fi= 4677- a67
2

3.
(iv) 'eoirveyances used : .fi) tlQ$*..bl.:..723. df:...n F A^"-
affifr qr6i r\ (Soo
(v) *Character assuined :....
'
+qm.*,&- tsgl Zrttlo-
ffii iqirr I t-ffi rars'ot
(Yi) 'Lantiuage/Slang us€d : .. ':"""n
{it€tfi qrqr I +6ff qrqr :

(vi0 Special Feature-1 _.........1......

ffvlc ARrd+ ,

(vili) *Speci6l Feature-2

ftrlqtnTd-r:
(ix)'Special Feature-3
HctRTd-r,
I
(x) Sype of PlacE of Occurence
u-atar fuoprsrtrdrr :
:.... -hssr_
filled) :..
 ? "rf
,'g
' "*ffiiffi'ffi"H"ffi,*,frt, ir requked) rd

Det6/ Natione-
FuttNeme
Ssx Ity
of Eirth
Religion so Uon Addr€is
Injury:
{EEf fl4 qqdit-s/ SI M
frq v$q-{ sd qrfr/ Simde
d Eqrfi
cIT
Sqwa g
(2)
(3)
t'4) ('s) ('6)
nftffi
f7) c8
{10) {'
14

n &q f { ra o
h
tt
s o@
A I
i
,Y F a e
1
I
I
oE 0d-

.l

6. Motive of Crime
] ffllsrh g{r6{Erd* Erq6fdi. . - ''' ' " . . . . . . .
' - .i . . . .. . . . . . .
. . . .. . . . . . . . .

J
' "#;#"HgW ffiH,ffi,#,#e"" ;";" I

I
l

) .....,......'.............'.....'..... I

I
1. .........''......-......

.+,

i
j
"'$ffHrtg Ptace <roccu,ence

*t& % d, sJ. 4s\s

,n
I
L
Qo Llr6l-
q7+ 2. "+{?A
t|,I-lt:,A 3t-
F.R- | l0

<@F-
@esr- .taef
e#'€ \r
qTrIs;2r?=
Form: ll -'' . r.

21q 3 4:4L1 tW'', 1'-

ffiiti- rftrdi
-ryaifrI-
;€frru)
4i,ifl' eqr ,iW
"-',trifrr
EJ, q8r
''t;itffif
...tr@\r_<.* PPLZ U TgFr "
ilt6i1t'-'
){,9
't;*I - 7>s9
v*nwrdT aq"E
_-.,r-...-.,
ia1-'_ mHal;' 6
31 @
"r{
gsry
4tw."-
tfi41--r1r'
.ry-t{'rri-d- q;
ffivJr t <fi':
€@P,f
riur
u4- uirtair'

-'Ditle

tra
 *
frT *fu
8

.[
a+ qlr,a.o No
F
"ffi
)ffb d
(t.
erslf-
\E' o f8"
,D&D. CE
.r*t F l6
7c0
4
J
4
qtt6i' T
P.s.frn-oc .]
I

10. Description of physical evidence from the scene 6f crime for the property for thel purpose of
l
investigEtion :
qcrrorfr rflH grrqr €EIT5<rar vri-+w Fmf+eetfv< A+f,r qrdr+n soh i

vaf " Ptanrt-iz& .ry+- -'afusnant

Warp'tr lddq-'W-rilP- i

, -. . . I . . - .. . . , .,. . . . . .

'11. Date and limeofPanchnama :

qT{rqrff AaFfii6 4: 4'z\ Time olt Ri '!o Tfd
lrcqrerd td ,,1
L

eftr
'12. Name of P of Panlhas
qsrfl qri

(1)
H" }fuy *rfuqg* {EII

ffir rnL-Dr nt.trQ{ .8,B3oe8B?qo

tt .... zr:tf ....xmr-d).ef .f-/T'E ..3.6..Sf t.@. : ......... ..

FuttAddress:
-
;:*-*;1lq@antt1 '
q*C*tf-a
rn1ot.
fr#"
-.*E
r ,-'.1
6 w6-
NameandSig nature of
affi6siffirrfr
Date Narne
fr|ni-6 4'4'z'1)= riE : @elr-
Rank
4sL B. No. if anyi
a. t. qJfQS-
rrt+-is cz-d:tti- +rol-lo,ooo

q
I

Ec"d {Y

ar- ii ..:.
I ::j

. .: :i:11..-
'€.-=5;;r

' '&,

:+

Vz-
 I
'd

l
I
i

I
I

;
+
t
t{t
[r]1723353E,
lE
':.::: .
:r:..r

.i
fiI(,t{AEotrRrrHBarl
h.rE{qt
*
 d;ffi;; \
ihis poJicy sardbodb$ Support
Mafutl I GG Bfotlllu P.r'nrate.'timite.d
1 , Nelson M Rcad, Vasant Kunj, i{ar,r Delhi . 110 070
? 44,?F
-., . .,,_,, -+ I,nlt is .nqt, 4.p?$ ..ol.the..policy docu t.. Plaase petach Here. trBttr 0l1/WZlfrlxl044

#! terctGlombard
7r ICICI Lombard General lnsurance eo. Ll
Nibhaye l&acta .*,**..
IRDAI qegn- t'ro
CERTIFICATE CUM P L}cY ScHEDULE
Ol{lGL\lI fOR EEClllEliLDlrPll{I iE lox auPlJE&
T^IliafotcEExtlt tcaltct at rl{,Itlf,
of TBE CErir&4t
hrld4 OD 6lE1 ( Pde v6i.C,
ldtl/t Mllorrarra/oQ!fl la-S,*20t1 b lr-licFroU
l-.ELldd--ltt
Htt.ll[.dt [i- S.ii.t ES,IA
la!!l,!J:[t A6diE6.ld@ rytua
prrrf,E lroiriii^fl Bo Dr^fFari& aNaijltEDoGAI Gtot xD l(Arot, IoAD-,
NAO?IE-.1.O0I!, f,Lf,fEtu.
rr,=,r.i'tr r?E f,Fnfrr-i-!=E-:+fuEtElffi--airfiTjasirtir-
II\'SJXTD X)TOR TUSICLE DEIAII.S DECLAXED VALUE
9,Jr,
MH! lltBOO Elddail'Ae*'i*'--
u{v Ltt! l(n o
r67r,l.x lcticltll,tqrrc 9ljt5l
ta6:t
6

RIO las&r i{rtlFll5a6 /irAGPLiR

.
wqtut0
owli DA!({GE SICII{)N l^l
,!t0 Lro
o rer hat-03E6:t,uiqofio
o l+S+2r10
!r!.4!nI!--.--
Er!'i PMi.D Dtrh4r l!E]! CN(n|.lC
0

,i, llts . IE1"{ AUIET'OIIIE LTD, NAOtlA

! 0 :I IE Si.d.l'. OS Lg., )
D{ii4 t&&r -e.(i (,D lE&iar lsota)
FlaiJ'&6. a.!*i6.5 dE Eli.aid .f.!.4e
ir
e C@.dit Ed* r.a65*E !t +.t
Irc hlq n d*lr b.6r{s.v D.d..aU. of & l0& d T -Zl)
Uo!s& D,i..6k {:l}r !24) ! Ssliccro ldGrd. EIT
A!8i-ThdtDqic a6at40t o r}.C.tat llrb lI.,.u., lr €1, L. Oa D.4F En.o i.[.r !.tiut, L
0
.-*.rid 'i* tL r$da
$'rr& rE lb. iEEd rdst t rltsihrt oftL rdidt holtJ. EId PoBrtu Unb
t 146 C(&d G1rq C6i5... rde d! f@.ini6e. t 47ti6!rr, @ i! 6.d d
rdr,@.(6. go&r sd ud.rEl6 b lsffi rd E{ilri, . v.lit rd tftait! tt C
oE6d 6.Y&i(t! d.a; Ebdltr rd C.ffi*,! didL. dnilsll.tficEddt DoUr,. F{dd, e
I5& -db.66
C.r?.,r' ,Er!. & 4b 6 d! qF!r.i&.dn! h 4 of.r!_ dtr,f,Ea h dt iOC
dtuddi6€r
,Jt! Iln rd4rrnid- & n+ftor-&d,e rd h.lsranbr -
I666 ^!i{id"
Yails: {lo@ltr{! T.s aE ' l8oo5?2o19,
tt52
250

rlU
Na m D.!.r. lBir L4l t@t7
ccsr@* trrrj3
lcfis* ll11Jt
t1962

No5hl.Dc{rlb : NoELaa Nada roz!'i 1t rurEotl lrrE

PsrEttst D.!il Prylianr M.drod Ch.crc XoJrrr{lacrho N 'AEAD &*ls. Anlo!!t

llo?fl6r ll0 EJtcrio ctaYMBII lw2
i'iunder T_Yr. Nrhr .&r BIrnEb NA
lEi.lr., r. It r lt Fdq c66Ea oa6. r$i& 6r!,a Erl C"n'.E..., r-a tA. *- !@l(s 6 Fied krriE l, c, OEiEind E&E, O PE
rdPo.. d.r&n: rJ Hia(
r) SFcd Etd.a. 0 xdi4jlirt Tlid!, d .\s'rE4o. n *_'{"; bi6 H*. TEic. I

Fd irdildat @t!d. Pto\lri.ti 6.t. h.lli60.oI&*dldrdirEraia{diftdtu h$,sd.rrnd4El.Ii@i:

dd lb. tcfu idltr{ u {Edv. lrllalr l. ccs oqis d. Erri,@ns of Rr! J dtu Gdd ltdsl_diidil.lF- l9!1.
.ctihls: I).&drbb 6ds Ecr@r: tu llll0(C@Fld-a Dlleotb a. l0oOrdF.d Irt- 0 d \_dG lHrdliL R! 0l I

! O.no 86{.: flE @r,l it lidilLd h.lio Cllii Sos (ilCE, 6 {E O$. D,EE!. Edd of EDoIo, ifD.l& i.E d Dcfllits.d'B lld F.ed{ !q{,I rFi U.6Etui!$ ft G

.oirFniE:re:.'.' trEdaEDlr@: ir Hn$ rd deriE rsEArX Pd.elir3 Fe Cddiir. !-E/5o:( rlo Clln 9d *il!
ir N€l€ i;i,h i, d+..;r +ir .iJ -i.i; i
!i.sftl-:d-ial!i.s.L.t!lca.yE,-E J!Dd,b t &q'o! b-.!Mors .rEii6
6iJiita.lrit tiat ;!i4iet;tuH.{. lliha{cEa4ff,1l*rElds}raDe|GtlToE
Lld Ex|i$ s.!
orbbEdl.tsr..rME trlu ttfi ri6.iL: tB.r'*E
Cdin .rEI5.r!sc[!6i5 iE{ ir eils.i6r[.lEriiB.JCbrqt &d cldd'xt rf [t!. a.L !qt!. I

tor lctct LoalEAxD GENER {l !,{SlrLArlcE co l-rD

ffi nr*y Ur*r oari t-o4 Frr . &.!.i

CSTTN:
d ffi lclcl bdE
:r^AACl?96lOUrl. Cld l
l*ir4:l
I ia*.diffilE[rduroor'
&-
l@sn4stl4..!

http://1 0.5 8. L l 0/Ilarutilnsu int.aspxlp... 91112021

L;j.-'
 "J

I
I

i
I

\
i

i
I
I

I
I

l
 i

Rajendra rajurkar
35/MALE
22441369

N,K;P I
an [iite 'l
eei
Dlgdoh 1

n ! 3 i:
't:

Name RAJENDRA RAJURI(AR

UHID 224U1369
4ad/sex
#1rvt,:.i:i
Address IGCHERA SAWAN GA, KA
t
Date iot surgery 2uuno22
.P!SF.
o .rsll-grj
EMERGENCY CO NTACT NO:-o
71046650@

UNIT 1
UNIT INCHARGE DR. SUSHIL MANKAR
ASSOCIATE DR. MOHAMMAD
PROFESSOR
B ;
SENIOR DR. RAH UL SAKHRE
E D
ir ,il#
RESIDENTS
'J-u!ioB i ;.,,11"r.i...Dh.
a ]
45
lls'.PEsNrs_Jr;i ;on

Diaqnosis

CA SE OF POTYTRAUMA
- FRACTURE R fl.lltc ELADE
o FEMU& FRATURE NIbHI'PROXIMAt
FRACTURE , 8II.A
MAXII.IARY StNiUS
RIGHT INIERIROC}IAITIERTC

FRACTURE.
Ma4aqement

OPEN RED UCIION IN reRNat

FIXATION P
FEMUR FRACTURE WiTH NAIT FOR I IVTE
OPEN AND II'IIERNAI. FTXAIION Wmt
cc scREl rs
Bricf history Patient complaifl paln and
over rlght lower flmb slnce
A./HilO RTA I hour back hit 6 houE.
unknown vehld!
h/o loss of consciousness
h/o ent bleed
h/o chest trauma
h/o breathelessness
No h/o Diabetes, Asthma.
id disorder,HTtf
No h/o any surgical illness
ln e past

I
 A
)

2:24041369

3s/MAtE
Raiendra raiurkar

t
ceniiri[r'. . ',
]:..
']:
.tP
' :,:::l:l:i'' 'i:,
"*aqlriJi!";
't', . i!.-11i r:: :.

r,. .,:,..r.i.r:' ',.. ; ] ri

orr

Left HiP
Local examination present
swelling
Absent
External

Deformi
Present
o
p Normal
Local Te Present
Tend Absent
CrePitati
Abnorm mobilrty
fll,.l,l,l""0 '"o"o"o
ROM

Left kne plesent

S!.rellin absent
Erterlla wPund absedt
Deforarr
PilPa normal
Local t p
present
Tend e e35
absent
CreP oIl
al mobilitY
absent '
Abnor painful and restrlcted
RON4

o
ptrt lf,
-ffT
BLOOD
HS
Ir,lvESflGAnoNs
B
3 roooo
24ZUu I
UR lzl I

CR
0.8
N{ -l 133
r 3.s
AL
BI
Di IECT 0.10

I lffE 0
c t lLl
z
 Rajendra rajurkar
3slMAtE
224Ut369

SGOT 35
SGPT 17
SERUM 85
ALKPO
4
ESR 22
CRP 2.90
INR 1.39
Hlv NEGATI
VE
HBSAG NEGATI
VE
HCV NEGATI
VE

a PROCEDURE:
OPEN REDUCTION IN RNAL FIXATION W rfn'enoxlun-
rruuR
NAIL, OPEN REDUCTI N INTERNAL FI)GTI qN W|TH
CC SCREW

SURGEON: i
DR.RAHUL,DR.YASH, R.RISHIKESH
ANAESTHETIST:
DR. TAJNE

OT NOTES:
Under all ase ic precautions.
a Under combin spinal and epidura anesthesia.
? Patient taken n Supine position on he fracture table.
a Reduction a mpted with traction nd manipulbtion
and
observed und r c-arm.
. Cleaning, pain ng and draping don
o lncision taken f about 5 cm from t
o. proximally.
e GT and extended

Entry taken w hthe help of bone just lateral to the

pyriform fossa Guide wire passed pushed into the distal
fragment.
a Entry taken wi h the entry reamer a(rd followed by reamming
with no 9,10 ammer. i

Nail of size 11 250 x 135 passed ovbr the guide wire.

a Proximal locki done with 90mm qnd gomm bolts.
a Distal lockihg as done with 34mm Screw a nd 32mm
screw.
a Reduction checked under c-arm and found to be stable.
Adequate wa's was given.
Closure was d ne in layers.
Procedure wa uneventful.

3
 22N41159
3slMALE
Raiendra raiurkar

TIBI M ANAGEMENT
GA
UN ER AAP , UNOER PAINTING DONE'
ABLE, CLEAPTNG
P tNT TAKEN ON OTT
UNDER CARM.
FR UR E SITE CHECKED
LATE RAL ASPECT
OF RrcHT LEG ON
INC SrcN TAKEN ON $NSERTED THROUGH
2X 6.5 MM CCSCREW
x MAL ASPECT.
PR FRACTURE
THE PROXIMAL TIBIA.
li1 F]R ACTURE SITE INTO
CLOSURE DONE IN
LAYERS
FC t\ D TO BE REDUCED. D PROCEDURE
PR UNEVENTFU L. PATIENTTOTERATE
CE DURE
L

PATI€NT WAS INI KEFTi\ D 1.5GM IV BD FOR

3 DAYS o
GIVEN: INJ f\Ml[iA 0.5 G IV BD FOR 3 DAYS
SION 1G IV BD FOR
3 DAYS
' rNt pcul t F

INJ TRAI'il op L
IV BD FOR 3 DAYS
MG OR OD FOR 3
DAYS
INI PAIJ
OR BD FOR 10 DAYS
TAB ORr',7 L |c! 63sM
G
FOR 14 DAYS
TA9 PAI.i 0rvl GOROD
14 DAYS
T C;\I.: i '!, p R OD FOR
T Lll"l LI D FOR 10 DAYS
Ro
10 D AYS
Cp.i) Bl_il u LE OR OD FOR
T/:,,tJ U!-'a:i os gpFgR 14 EAYS
FOR 4 DAYS
TAar cil ., RAL FORTE OR TDS

TAB CLlr AI EPAM.O.25 OR BD X15 DAYS

IM X S.,DAYS
l[,'li THirt INE 1OOMG
ALL 2CC lM OD x15
DAYS
INJ YlTi
BD X 15 DAYS
TAts Ri', L! T E O.sMGOR
TAB ti: 5 OOMG OR BD X 7
\
DAYS

rj DO NE- ADVISED STJRGER

Y FOR LEFORTS 2
FRACTURE o
Ol,/rF5 !-,
ABI,SIVE BEHAVIOUR
PSY C D NE I/V/O'IRRITABLE'AND
P

Patlent stable
Afdbrlld-
Sutures not lemoved
Wound site healthY
WHENTO CO TACT
. PAIN
-swEtuNG
-DISCHARGE
- anV f nSX COtt'tPfnNTs

65000
IMH

L
 <}

Rajendra rajurkar 35/MALE 2240,41369

ADVICE ON DISCHARGE : N€ar by hospital

TRANSFER TO OMFS FOR FURTHER MA EMENT

NON.WEI6HT BEARING MOBIIIZIION

HIP ROM, KNEE ROM , ANKTE ROM

CONTINUE PHYSIOTHERAPY AS ADVISED

CONTINUE MEDICATIONS

FottOW UP ON MONDAY AND 2nd and 4rh TURPAY

SUTURE REMOVAL ON POO 12.

o TREATMENT ON DISCHARGE:

o
DR. SH S. SHEWA LE
4o
JR. DEi itr I )f,
llKP';!,,t;f. ir i;i:
f;i 0i '".E D loti
oR.RhH0v At
U l(, 20irt;.i,dt''
HOUSE OFFICER LECIURER /A.P. UNlT INCHARGE
UNIT.1 UNIT 1 UNIT 1

5
 .r-

?.24o4L359
35/MALE
Rajendra raiurkar

j!
rii:

1
,$

o
PRE O

!
POST OP

o
t

6
{-
l
ffi .6\o,,
.sITETT

.l
e f alr

erTrifl-q'frftiq :rt@ , srB--qflTT

Unique ldentification l\uth ority of indid,
lklt Ef6:/ Enrdment No. 2qJ6,1316761486.78
TO
r& sfd{ErEla.r
Rar€.I('e t or'f.o R.rurbt I
Wfid t5. 0t
SaoaFr Roed
Itar thruman andk
At Arurwa&,H. l,taregaqr
traksEoat
lb$rll it*lataCt'a . .t{1107
9164791261t

ffiffi"

3{rrmr 3mrir 6-siq-/ Y r Aadhaar No. :

3,3 75 2t 23 3732
VD 913.t El 17 9 2992
qr+ 3{rqrc, 3+6s
*
s 7A\,.

rr*rtidE
REJ€nda tkf,fro Rart/Ib,
Fd drtvmB 9E?
l6V MAlr
i
e
,

3375 2123 732

3{Ttfirf }Il-dGr
 I

I
2't8 4,
I

T,

o tiarcc d'.a erllr gG dr

iii + Centrol Bonk ot lnciia $
.i :. . rl.'
NI k ,:,!
ri-ii t
E *i, 'i i

'tddre ss,rid rFi;ii*if:', It

trt itr
tit.l i,ait-t.11.

-i
-';i:-f'
*:
CT cHe:1 I il I 6505
li[trtu t9fl
i
'li -.'t:
...
i.- lrti

..i
 i+

ft
6
*
al
a
EI ffi t
n. *w
I
l{

I
I
qrsF
rr
*
Etr:E
k

:r
t
:.:
't,r

fficd#.