Page 747 - The Central Motor Vehicles Rules, 1989

ANNEXURE-XIII THE CENTRAL MOTOR VEHICLE RULES, 1989 719

Loss of earning, inconvenience, hardships,
disappointment, frustration, mental stress,
dejectment and unhappiness in future life, etc.
Total compensation
31. If the Insurance Company does not admit the liability to pay the compensation,
disclose the grounds on which the Insurance Company wants to contest the claim:
Verification:
Verified at .......................... on this ......................... day of .................... that the contents
of the above report are true and correct. I am well conversant with the principles of
computation of compensation and have applied the same to compute the compensation.
DESIGNATED OFFICER
1. Report of the Surveyor/Investigator
FORM-XII
VICTIM IMPACT REPORT
By State Legal Services Authority to concerned criminal court within thirty (30) days of
conviction and to be considered at the time of sentencing
S. No. Description Particulars
1. FIR No., date and under Section(s)

2. Name of Police Station
3. Date, time and place of offence
4. Nature of injury/loss suffered by the victim(s)
i. Physical harm
a. Simple injuries
b. Grievous injuries

c. Death
ii. Emotional harm
iii. Damage/loss of property
iv. Any other loss/injury
5. Brief description of offence(s) in which the
accused has been convicted
6. Name of the victim
7. Father’s/Spouse’s name
8. Age
9. Gender
10. Marital status