Page 750 - The Central Motor Vehicles Rules, 1989

722 THE CENTRAL MOTOR VEHICLES RULES, 1989 ANNEXURE-XIII

34. Whether the injured got
reimbursement of medical expenses

35. Details of family/dependents of the injured:
Name Age Gender Relation
(i)
(ii)
(iii)

(iv)
(v)
(vi)
36. Details of losses suffered
Pecuniary Losses:
(i) Expenditure incurred on treatment,
conveyance, special diet, attendant, etc.
(ii) If treatment is still continuing, give the
estimate of expenditure likely to be
incurred on future treatment
(iii) Loss of income
(iv) Any other loss which may require any
special treatment or aid to the injured
for the rest of his life
(v) Percentage of disability assessed and
nature of disability as permanent or
temporary
(vi) Percentage of loss of earning capacity
in relation to disability

(vii) Loss of future Income
(Income x % Earning Capacity x
Multiplier)
(viii) Any other pecuniary loss/damage
Non-Pecuniary Losses:
(i) Pain and suffering
(ii) Loss of amenities of life,
inconvenience, hardships,
disappointment, frustration, mental
stress, dejectment and unhappiness in
future life, etc.