FORM‒G

(See rules 8 and 20)

Application for grant of compensation under the Motor Vehicles Act, 1988

BEFORE MOTOR ACCIDENT CLAIMS TRIBUNAL,

TALCHER.
MAC CASE NO………………………/2024

1. ANITA DANDIA, Photographs Of Claimant

Aged about- 40 years
W/O- Late Gagan Dandia

2. SMITA DANDIA,
Aged about- 16 years
D/O- Late Gagan Dandia

3. ANKITA DANDIA ,
Aged about- 13 years
D/O- Late Gagan Dandia

4. BIJULI DANDIA ,
Aged about- 70 years
Mother of -Late Gagan Dandia
W/O- BidyadharDandia ,

All the above Petitioners are residing ,

At Vill- Belapada, Po- Radharamanpur,
Ps- Talcher, Dist- Angul, Odisha
Pin-759100.
(As petitioner No- 2 & 3 are minor & unmarried Daughters of the deceased , hence ,
represented through their mother Guardian Petitioner No- 1.)

_____________________________ Petitioner ‘s

Vrs..

1. SANTANU BARIK,
Aged about- 43 years,
S/O- Bikram Barik,
of Vill- Hensamul, Po- Hensamul,
Ps- Colliery, Dist- Angul, Odisha
Pin-759103.
(Owner of the offending Vehicle vide Regd. No.- OD-35-F/ 6528,
TATA LPT 4825 BS VI 10X2 , Truck Open Body)

2. ICICI LOMBARD GENERAL INSURANCE COMPANY LTD.

(Represented through its Authorized Signatory),
At: 3rd Floor, Anuj Building, Plot no.29,, Satya Nagar,
Bhubaneswar, Odisha , 751007.
_____________________________ Respondent’s
Sir,

Page 1 of 9
 The undersigned makes this application for grant of compensation as per the
provisions of the Motor Vehicles Act, 1988 on the basis of the following facts and
information:―

PART-I
1. Name and Father’s name of the person dead .
(Husband’s name in the case of Late. Gagan Dandia ,
married woman and widow): S/O- Late. BidyadharDandia .
2. Full address of the person dead: At Vill- Belapada,
Po- Radharamanpur,
Ps- Talcher, Dist- Angul,
Odisha
Pin-759100.

3. Age of the person dead: 43 years .

4. Occupation of the person dead: Tipper Driver

5. Name and address of the employer of the dead:

At- RKTC-BLA-RAPL(JV),
( A Private Transport Company ,
working At- Bhubaneswari Open Cast
Project , MCL, Talcher .

6. Monthly income of the person dead: Rs. 25,000/- Per month

(Approximately)
7. Does the person in respect of whom
compensation is claimed pay income tax? NO
If so, state the amount of the income tax
(to be supported by documents):

8. Place, date and time of accident: In front of hazir office of BLA

Company , At- Bhubaneswari OCP, on
Dtd:- 30-03-2024 , at about 08:45 PM .
9. Brief particulars of the accident:
On Dated 30-03-2024 , At about 08:45 PM , while the above named deceased ,
were proceeding towards BLA Company in order to attend his Night Shift Duty along with
one of his friend , namely Prasant Kumar Parida, S/O- Pankaj Parida of Vill:-
Manikmara ,IGIT, Sarang, Dist:- Dhenkanal,Odisha, in his motor cycle(Hero Honda)
Vide Regd. No.OR-19-P/2795, as a pillion rider , all of a sudden in front of the Haziri Office
of the said company , a TATA LPT Truck vide Regd. NoOD-35-F/6528 , coming from
opposite side , in a very rash & negligence manner , dashed the motor cyclist , due to which
Prasant kumar Parida (Rider of the motor cycle) fell down from the motor cycle having
grievous bleeding injuries all over his body& subsequently died on the way, while shifting to
medical, whereas Gagan Dandia died on the spot as has been run over by the truck tire of the
said offending vehicle . the accident occurred only due to rush and negligent driving of the
driver, of the said offending truck .

10. Name and address of police station, Talcher Police Station

in whose jurisdiction the accident took place,
or was registered:
Talcher, Dist- Angul, vide
PS Case No:- 0321/2024,U/S. 304-
A of IPC , Corresponding to GR
Case No:- 575/2024, of the case
record of the Learned SDJM.,
Talcher.

11. Was the person in respect of whom Yes,

Page 2 of 9
compensation is claimed traveling by the from his homesituated at
vehicle involved in the accident? Radharamanpur on amotor
If so, give the name and place of starting cycle(HeroHonda) Vide Regd.
Place ofthe journey and destination : No.OR-19-P/2795,as a pillion
rider ,to BLAcompany , situated
atBhubaneswari OCP, MCL,
Talcher .

12. Nature of injuries sustained and Brain Injury , rupture of lungs

disablement, if any, caused: &vital organs .
(Post-Mortem
Report of the
Sub-Divisional
Hospital ,
Talcher to be
referred for details).

13. Name and address of the Medical Officer/ Dr. Soumya Dikshit
Practitioner if any, who attended Sub-Asst. Surgeon ,Sub-
to the dead person: Divisional Hospital , Talcher

14. Period of treatment and expenditure, if any incurred: Not Applicable

15. Registration No. and type of vehicle OD-35-F/6528,
involved in the accident: TATA LPT 4825 BSVI 10X2 , Truck Open Body
(Offending Vehicle)

16. Name and address of the owner of the vehicle: SANTANU BARIK,
Aged about- 43 years,
S/O- Bikram Barik,
of Vill- Hensamul,
Po- Hensamul,
Ps- Colliery, Dist- Angul,
Odisha, Pin-759103.

17. Name of the driver of the vehicle: Bikram Samal

18. Name and address of the ICICI LOMBARD GENERAL
INSURANCE
insurer of the vehicle: COMPANY LTD.At: 3rd Floor, Anuj
Building,Plot no.29,, Satya Nagar,
Bhubaneswar, Odisha , 751007.

19. Has any claim been lodged with the

owner/Insurer if so, with what result: NO
(necessary documents to be annexed)

20. Name and address of the applicant’s: As per the cause title.

21. Relationship with the deceased: Petitioner no.01 is the widow of

the deceased , petitioner nos. 02
& 03 are unmarried minor daughters
And petitioner No. 04 is the mother of the
deceased respectively .

22. Title of the property of the deceased: Legal Heirs.

23. Amount of compensation claimed and basis thereof: Rs. 40,07,584/- ,

( Rupees Forty Lakh Seven Thousand Five Hundred Eighty Four ) Only .
Page 3 of 9
 HEAD’S
A .Monthly Dependency Rs.25,000/- Appx.( average of last three month wages
drawn /credited by the employer , as per saving bank account of the deceased .
B .Future Prospects (25% of monthly dependency) Rs.6,250/-
In case the deceased was self-employed or on a fixed salary, an addition, of 25%
where the deceased was between the age of 40 to 50 years as per the land mark
judgment :-
IN THE SUPREME COURT OF INDIA ,
CIVIL APPELALTE JURISDICTION ,
SPECIAL LEAVE PETITION (CIVIL) NO. 25590 OF 2014 ,
National Insurance Company Limited …Petitioner(s)
Versus
Pranay Sethi and Ors. …. Respondent(s)

Total of A + B = 31,250/-
C.1/4th Deduction towards Personal Expenses of 31,250/- = Rs.7,812/-
one-fourth (1/4th) where the number of dependant family members is 4 to 6, as
per the land mark judgment :- IN THE SUPREME COURT OF INDIA ,
CIVIL APPELLATE JURISDICTION, CIVIL APPEAL NO 3483 OF 2008 ,
(Arising out of SLP [C] No.8648 of 2007),Smt. Sarla Verma &Ors….
... Appellants Versus.
Delhi Transport Corporation &Anr. ...
Respondents
D. Total Dependency (A + B – C) =Rs.23,438/- Per month .
E. Age Multiplier 14 , ( for 41 to 45 years)
As per the land mark judgment :- IN THE SUPREME COURT OF INDIA ,
CIVIL APPELLATE JURISDICTION, CIVIL APPEAL NO 3483 OF 2008 ,
(Arising out of SLP [C] No.8648 of 2007), Smt. Sarla Verma
&Ors. ... Appellants Versus.
Delhi Transport Corporation &Anr. ... Respondents

F. Compensation (D x 12 months x 14 multiplier)= Rs.39,37,584/-

G. Loss of Estate Rs.15,000/-
H.Funeral Expenses Rs.15,000/-
I. Consortium Rs.40,000/-
Total Compensation claimed Rs. 40,07,584/-
( Rupees Forty Lakh Seven Thousand Five Hundred
Eighty Four ) Only .
24. Whether reports from the Investigating Officer and the Registering Authority Have been
obtained in Form‒A and Form‒D ? (If so, to be annexed): NO
25. Whether affidavit of the Applicant and witnessed as per rule 8 are annexed (give details):
Yes
26. Whether documents mentioned in rule 8 are being annexed duly indexed (give details):
Yes
27. Any other information that may be necessary and helpful in the disposal of the case:Yes

PART-II
(To be filed if prayer is made for interim award)
28. Amount of compensation claimed as interim award. :-Not Applicable

Page 4 of 9
 29. Reasons for claim of interim award. :-Not Applicable
30. Whether documents mentioned in sub-rule (4) and sub-rule (5) of rule 20 have been
annexed (give details):-Not Applicable

31. PRAYER
Hence, it is prayed that, your honour may be graciously pleased to allow this petition
and further be pleased to grant a moderest claim of compensation worth of Rs. 40,07,584/-
( Rupees Forty Lakh Seven Thousand Five Hundred Eighty Four ) Only in favor of the
petitioners along with interest @ 7.5% per annum from the date of filling of the application
till payment made by the opposite parties and for such act of your honours kindness the
petitioners shall remain ever pray as in duty bound.

(Petitioner’s)

VERIFICATION

Verified, at __________________ this __________ day of _________ 2024, that the

contents of the above application are true and correct to my knowledge and belief.

(Petitioner’s)

IN THE COURT OF THE 3rd MOTOR ACCIDENT CLAIMS TRIBUNAL -CUM-

ADDITIONAL DISTRICT JUDGE, TALCHER.
MAC CASE NO. / 2024
ANITA DANDIA&ors. ………………….….……….. Petitioners.
Vrs.
SANTANU BARIK&anr ………………………… Opposite Parties.

AFFI DAV I T

I ANITA DANDIA ,Aged about- 40 years, W/O- Late Gagan Dandia, At Vill-
Belapada, Po- Radharamanpur,Ps- Talcher, Dist- Angul, Odisha , Pin-759100. do
hereby solemnly affirm and state as follows :-

1. That, I am filing a claim in FORM‒G ,(See rules 8 and 20) of the M.V.act 1988 , read with
THE MOTOR VEHICLES (AMENDMENT) ACT, 2019 NO. 32 OF 2019 &
Page 5 of 9
 ODISHA MOTOR VEHICLES (ACCIDENTS CLAIMS TRIBUNAL) RULES,
2019;before this Hon’ble Tribunal on this day along with my twominor & unmarried
Daughters and Mother- In-Law respectively naming asSMITA DANDIA,Aged about- 16
years ,D/O- Late Gagan Dandia, ANKITA DANDIA , Aged about- 13 years, D/O- Late
Gagan Dandia&BIJULI DANDIA , Aged about- 70 years,Mother of -Late Gagan Dandia,
W/O- BidyadharDandia.

2. That, I along-with rest of all above mentioned petitioners ,claiming motor accident
compensation on account of death of my husband Late Gagan Dandiaand I have no adverse
or alien interest against other petitioners .

3. That, I have claimed compensation worth ofRs. 40,07,584/-( Rupees Forty Lakh Seven
Thousand Five Hundred Eighty Four ) Only , as against the Opposite Parties 1 & 2,
towards death of deceased Gagan Dandia, in a motor vehicle accident occurred on 30-03-
2024 , at about 08:45 PM ..

4. That, we are and shall pursue the present claim against the Opposite Parties hereto through
our advocate Manoranjan Patra &Associates , Talcher and we solemnly affirm not to lay any
further claim as against the Opp. Party No.2 inter alia the OP No.1 in this Court or in any
other Court of concurrent jurisdiction, on account of the same-such cause of action.

5. That the contents made here-to-fore are true and correct to the best of my knowledge and
belief without any material concealment or exaggeration.

Identified by;

Manoranjan Patra,
Advocate Deponent

IN THE COURT OF THE 3rd MOTOR ACCIDENT CLAIMS TRIBUNAL -CUM-

ADDITIONAL DISTRICT JUDGE, TALCHER.
MAC CASE NO. / 2024
ANITA DANDIA&ors. …………………….……….. Petitioners
Vrs.
SANTANU BARIK&anr ……………………… Opposite Parties.

PETITION FOR INITIAL EXEMPTION COURT FEES FILED BY THE PETITIONERS

Most respectfully sheweth:-

1. That , the petitioners have filed the present claim FORM ‒G , (See rules 8 and 20) of the
M.V.act 1988 , read with THE MOTOR VEHICLES (AMENDMENT) ACT, 2019 NO.
32 OF 2019 &ODISHA MOTOR VEHICLES (ACCIDENTS CLAIMS TRIBUNAL)
RULES, 2019, of the M.V.act 1988 before this Hon’ble Tribunal on this day, on account of
death of Gagan Dandiain a vehicular accident.

2. That, for the purpose of valuation and jurisdiction the petitioners are required to file
the requisite court-fees along-with the claim application ,but not filed herewith inasmuch as
in eventual demise of the sole bread earner of the family the Petitioners are now leading a

Page 6 of 9
 very miserable life and as a matter of fact become unable to bear the initial litigation
expenses.

3. That, the petitioners have lost financial strength to pay the requisite court fees for the
valuation and jurisdiction, which is payable on the application, but not paid but the law-
abiding poor Petitioners vouch to pay the requisite fees prior to receipt of award of
compensation.

PRAYER

Under the premises, Your Honour may be pleased to allow the petition and be
further pleased to pass appropriate orders exempting the Petitioners from paying the
requisite court-fees, along-with the claim application with a leave to pay the requisite fees
prior to receipt of award of compensation for the ends of justice and equity;

And for such act of kindness the Petitioners shall ever pray.

By the Petitioners (T)

Manoranjan Patra
Advocate
rd
IN THE COURT OF THE 3 MOTOR ACCIDENT CLAIMS TRIBUNAL -CUM-
ADDITIONAL DISTRICT JUDGE, TALCHER.
MAC CASE NO. / 2024
ANITA DANDIA&ors. …………….…….……….. Petitioners.
Vrs.
SANTANU BARIK&anr ……………………… Opposite Parties.

A D D R E S SS T A T E M E N T

PERMANENT ADDRESS OF THE PETITIONERS:-

Name:-ANITA DANDIA,
Aged about 40 years,
W/O:- Late. GAGAN DANDIA
Residing At Vill- Belapada,

Po- Radharamanpur,
Ps- Talcher,
Dist- Angul,

Page 7 of 9
 Odisha ,
Pin-759100

By the Petitioners

IN THE COURT OF THE 3rd MOTOR ACCIDENT CLAIMS TRIBUNAL -CUM-

ADDITIONAL DISTRICT JUDGE, TALCHER.
MAC CASE NO. / 2024
ANITA DANDIA&ors. ……………….…….……….. Petitioners.
Vrs.
SANTANU BARIK&anr …………………………… Opposite Parties.

MEMO OF PROCESS FEE

In the above noted case, the petitioners have affixed court fee worth of Rs.03/-
( Rupees Three) Only, towards Process fee in this hon’ble court.

Page 8 of 9
By the petitioners

Page 9 of 9