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
