Page 748 - The Central Motor Vehicles Rules, 1989

720 THE CENTRAL MOTOR VEHICLES RULES, 1989 ANNEXURE-XIII

11. Addresses:
Permanent

Present
12. Contact information: Mobile
Email ID
I. Death Case

S. No. Description Particulars
13. Name of the deceased
14. Father’s/Spouse’s name
15. Age of the deceased
16. Gender of the deceased
17. Marital status of the deceased

18. Occupation of the deceased
19. Income of the deceased
20. Name, age and relationship of legal representatives of deceased:
Name Age Gender Relation
(i)

(ii)
(iii)
(iv)
(v)
(vi)
21. Details of losses suffered
Pecuniary Losses:

(i) Income of the deceased (A)
(ii) Add-Future Prospects (B)
(iii) Less-Personal expenses of the deceased
(C)
(iv) Monthly loss of dependency
[(A+B) – C = D]
(v) Annual loss of dependency (D x 12)
(vi) Multiplier (E)
(vii) Total loss of dependency (D x 12 x E = F)