Page 710 - The Central Motor Vehicles Rules, 1989

682 THE CENTRAL MOTOR VEHICLES RULES, 1989 ANNEXURE-XIII

4. Nature of case Simple Injury
Grievous Injury
Fatal
Damage/loss of the property
Any other loss/injury
5. Registration Number of the
offending vehicle
6. Owner Details

Name
Address
7. Driver Details
Name
Address

8. Insurance Details
Policy No.
Period of Policy
Name of Insurance Company
DEATH CASE
9. Name of the deceased
10. Father’s Name
11. Age/Date of Birth

12. Date of death
13. Gender of the deceased
14. Marital status of the deceased
15. Occupation of the deceased
16. If the deceased was employed, give
the name and address of the
employer
17. Income of the deceased
18. Whether the deceased was assessed Yes No
to Income Tax
If yes, file the copy of Income Tax
Returns for the last three years
19. Whether the deceased was the sole Yes No
earning member of the family