Page 764 - The Central Motor Vehicles Rules, 1989

736 THE CENTRAL MOTOR VEHICLES RULES, 1989 ANNEXURE-XIII

Hospitals Involved:
Name 1. 2. 3. 4.

Details
VEHICLE DETAILS
Vehicles involved 1. 2. 3. ....
Corresponding owner(s)
of vehicles
Corresponding driver of
the vehicles
Insurance agencies: 1. 2. 3. ....

Name of
Representative
Contact details

STAGE-II : CLAIM DETAILS (to be provided by MACT)
Particulars Details
MACT case number (to be allocated by respective MACT)
Claim petition:
Number 1. 2. 3. ....
Date

Place of filing
Claimant:
Name i. i. i. i.
ii. ii. ii. ii.
.... .... .... ....
Address(es)
Contact
Relationship with
victim(s)
Aadhaar
Advocate representing 1. 2. 3.
the Claimant