Page 745 - The Central Motor Vehicles Rules, 1989

ANNEXURE-XIII THE CENTRAL MOTOR VEHICLE RULES, 1989 717

12. Name and Address of Surveyor/ Investigator
Name

Address
13. Date of Report of the Surveyor/Investigator
14. Date of Decision of the Designated Officer
15. Whether this Form has been filed within Yes No
thirty (30) days of receipt of DAR
If not, give reasons for delay
DEATH CASE
16. Name of the deceased
17. Age of the deceased
18. Occupation

19. Monthly Income
20. Details of Legal Representatives of the deceased
Name Relationship Age
(i)
(ii)
(iii)
(iv)

(v)
(vi)
21. Computation of compensation Amount in Rs.
Income of the deceased (A)
Add-Future Prospects (B)
Less-Personal expenses of the deceased (C)

Monthly loss of dependency
[(A+B) – C = D]
Annual loss of dependency
(D ´ 12)
Multiplier (E)
Total loss of dependency
(E ´ 12 ´ D = F)
Medical Expenses (G)

Compensation for loss of consortium (H)