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Public Liability Insurance Act, 1991

FORM I : Form of Application for Compensation

Shri/Shrimati/Kumari son of/daughter of/Widow* of Shri _____________________ who died/ had sustained injuries in an accident on ________________ at _______________ particulars in respect of accident and other information are given below:-

1. Name and father's name of person injured/dead (husband's name in case of married woman or widow)

2. Address of the person injured/dead.

3. Age _______ date of birth ______________

4. Sex of the person injured/ dead

5. Place, date and time of the accident

6. Occupation of the person injured/ dead

7. Nature of injuries sustained

8. Name and address of police station in whose jurisdiction accident took place or was registered

9. Name and address of the medical officer/ practitioner who attended on the injured/dead

10. name and address of the claimant/ claimants

11. Relationship with the deceased

12. Any other information that may be considered necessary or helpful in the disposal of the claim.

I hereby swear and affirm that all the facts noted above are true to the best of my knowledge and belief.

Signature of the claimant

*Strike out whichever is not applicable.

Public Liability Insurance Act, 1991 Back

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