Page 896 - The Central Motor Vehicles Rules, 1989

868 COMPENSATION TO VICTIMS ..........ACCIDENTS SCHEME, 2022 FORM I

the claim awarded and the date of payment made, which shall be used to populate
the quarterly report under clause (b) of paragraph 13.
24. Annual report
The General Insurance Council shall prepare an annual report on the working
of this scheme and submit the same before the Standing Committee, with a copy
to the Central Government.
FORM I
[Paragraph 20(1)]
FORM OF APPLICATION FOR COMPENSATION FROM
HIT AND RUN COMPENSATION FUND
I, .................................... son*/daughter*/widow* of Shri ............................
residing at ............... ............................ having been grievously injured in motor
vehicle accident hereby apply for grant of compensation for the grievous injuries
sustained. Necessary particulars in respect of the injury sustained by me are given
below:—
I, ................................... son of/daughter of/widow of* Shri ...............................
residing at ................. ................ hereby apply as a legal representative for the grant
of compensation on account of death/injuries sustained by Shri/Shrimati/Kumari
................................... son of/daughter of/widow* of Shri ................................... ...who
died/had sustained injuries in a motor vehicle accident on .....................................
at ................................. Particulars in respect of accident and other information are
given below:—
1. Name and father’s name of person injured/dead (husband’s name
in case of married woman or widow):
2. Address of the person injured/dead:
3. Age ......... Date of Birth ..............................
4. Sex of the person injured/dead:
5. Aadhaar Number of the claimant in case of grievous hurt or Aadhaar
Number of legal representative.
6. Copy of Passbook of the bank account of person injured/legal
representative of the deceased .........................................................…...
7. Place, date and time of the accident:
8. Occupation of the person injured/dead:
9. Nature of injuries sustained:
10. Name and address of Police Station in whose jurisdiction accident
took place or was registered:
11. Name and address of the Hospital/Medical Officer/Practitioner who
attended on the injured/dead:
12. Name and address of the claimant/claimants: