J.P.

Gadiya, Advocates High Court Requirements:

ACCIDENT REPORT
Person Injured or Dead full Name :
Address: ______________________________________________________________
_______________________________________________________________________
Native Place Address: ____________________________________________________
_______________________________________________________ Medical Bills:
Mobile No- 1)

Occurrence Place: Date: Time:

Name of the Road: ______________________________________________________

Occupation Income Sex Age Married or Single

______________ ___________ _________ _________ ________________

Name & Address of Employer _____________________________________________

___________________________________Tel. No. _____________________________

Injuries / Fatal:
________________________________________________________________________
1] Hospital: Admitted on: Discharged on:

2] Hospital: Admitted on: Discharged on :

3] Hospital: Admitted on: Discharged on :

________________________________________________________________________
Police Station: __________________________ Inv Officer ______________________

C.R.NO. / S.D.E./ T.A.R.NO :

Vehicle No. ___________________________ Type: _____________________________

Insurance Name: _______________________ Validity: __________________________

Policy No: ____________________________ Name of Driver : ___________________

Relation:-
1. Husband : ________________________________ Age : _________Sign :_________

2. Widow: _________________________________ Age : _________Sign :_________

3. Son /Daughter : ___________________________ Age : _________Sign :_________

4. Son /Daughter : _________________________ _ Age : _________Sign :_________

5. Son /Daughter : __________________________ Age : __________Sign :_________

6. Son /Daughter : __________________________ Age : __________Sign :_________

7. Father :________________ ________________ _Age : ________ _Sign :_________

8. Mother :______ ___________________________ Age : _________Sign :_________

In the case of Minor, Father’s / Next Friend’s Name: _____________________________

UNDERTAKING

I/We ________________________________ have filed

MACT/CEC/RCT case bearing No- ________________ before Hon’ble
MACT/CEC/RCT Mumbai/ Thane/ Kalyan. I/We will attend all the dates
as and when my/our Advocate and Court will call for Evidence OR LOK
ADALAT, I/We will remain present for hearing alongwith all original
required documents. I/We have not paid any fees & Expenses till today to
my Advocates as I/We don’t have money to pay professional fees and
expenses. I/We are also giving cheques bearing No__________ drawn on
______________ dt _____________ of Rs._______________ to my
advocates on account of his professional fees and expenses.
I/We are undertake to pay Rs._______________/- as professional
fees and Rs.__________ /- as expenses incurred by the advocates in the
above matter. If I/We will not attend the matter as and when called and
matter will dismiss then also I/We will pay professional fees and expenses
to my/our advocates as and when they demand.
I/We hereby undertake and affirm that I/We have not filed any case
earlier to this in respect of this accident. I/We further assure that I/We will
not file the said accident case in other court or with any other Advocate.
The above matter has been read and explained to me in Hindi &
Marathi and English is true and correct in best of my/our Knowledge.
Place :
Date :
X____________________________
X____________________________
X____________________________
X ____________________________
X ____________________________
(Applicant/s)
The applicant therefore prays that,

[A] The Opponents i.e. the Opp. Party and Insurer herein are jointly and

severally to pay Rs /- under section 140 of the Motor Vehicle

Act, 1988 with costs and interest to the applicants.

[B] Any other relief that the Hon’ble Tribunal may be found fit and

proper in the circumstances of the case be awarded to the applicant.

Place :
Date :

J.P.Gadiya
Advocate for the applicant Applicant/s

VERIFICATION

I/We, the applicant/s solemnly declare that the particulars given

above are true and correct to the best of my knowledge and belief and no

claim in respect of the same accident has been filed or pending u/s. 140.

U/s. 166, or section 163[A] of motor vehicle Act. 1988 before any other

forum in India.

Place :
Date :

J.P.GADIYA
Advocate for the applicant Applicant/s
The applicant prays that,

[A] The opponents herein are ordered to pay Just, Fair and Proper

Compensation from this Hon’ble Tribunal may deem fit and proper,

with interest thereon and the cost to applicant.

[B] Any such other relief that may be found fit and proper by this Tribunal

may kindly be granted.

Place :
Date :

J.P.Gadiya
Advocate for the applicant Applicant

VERIFICATION

I/We, the applicant/s solemnly declare that the particulars given

above are true and correct to the best of my knowledge and belief and no

claim in respect of the same accident has been filed or pending u/s. 140.

U/s. 166, or section 163[A] of motor vehicle Act. 1988 before any other

forum in India.

Place :
Date :

J.P.GADIYA
Advocate for the applicant Applicant
BEFORE THE MOTOR ACCIDENT CLAIMS TRIBUNAL
AT
M.A.C. NO- OF 2023

]...Applicant
V/S

AND
]…Opponents

Application for permission to Engage an Advocate.

I/We, the applicant in the above matter have filed the application
for compensation for the injuries sustained to me/fetal injury in a motor
vehicle accident.
I may be permitted to engage Shri J.P.Gadiya, _____________ as
an Advocate to contest and settle the above claim application before this
Hon’ble Tribunal.

Date this ______day of _________2023

Applicant/s
 VAKALATNAMA

IN THE COURT OF THE MACT/C.E.C.

APPLICATION NO- OF 2023

]...Applicant
V/S

AND
]…Opponents

I/We, the Applicant/s hereinabove appoint and authorize

Shri. J.P. Gadiya ___________________________________ Advocates,
High Court, to act, appear, plead and settle for me/us in the above matter.

In witness whereof, I/We, have put my/our hand/s to this writing.

Dated this_______ day of______________2023

Accepted:

Mr. J.P.GADIYA [Mah-250/C-1998]

(Advocate, High Court,) Applicant/s

Siddharth Tower,
Kopari, Thane (E) - 400603
Mob- 93242 12027 & 92247 87408
___________________________________________________________

MAY IT PLEASE YOUR HONOUR

Be pleased to allow me/us to act, appear and plead on behalf of the

Applicant/s in the above matter.
Dated this_______ day of ____________ 2023

Advocate for the Applicant/s

BEFORE THE MOTOR ACCIDENT CLAIM TRIBUNAL
At

M.A.C. NO- OF 2023

]...Applicant
V/S

AND
]…Opponents