Public Liability Insurance Rules, 1991
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.