Page 897 - The Central Motor Vehicles Rules, 1989

FORM II COMPENSATION TO VICTIMS ..........ACCIDENTS SCHEME, 2022 869

13. Relationship with the deceased:
14. Copy of bill given by the Hospital which has provided cashless
treatment as per Scheme framed under section 162 of the Act:
15. Any other information that may be considered necessary or helpful
in the disposal of the claim:
I hereby swear and affirm that all the facts noted above are true to the best
of my knowledge and belief.
SIGNATURE OF THE CLAIMANT
*Strike out whichever is not applicable.

FORM II
[Paragraph 21(2)(b)]
CLAIMS ENQUIRY REPORT TO BE SUBMITTED BY THE CLAIMS
ENQUIRY OFFICER TO THE CLAIMS SETTLEMENT COMMISSIONER
1. Name and address of the person dead/injured:
2. Place, time and date of the accident:
3. Particulars of the Police Station in which the accident was registered:
4. Particulars of the Hospital/Medical Officer/Practitioner who
examined the dead/injured:

5. Particulars of persons summoned and examined:
6. Whether the fact of death/injury by hit and run motor accident has
been established or not and the reason for coming to that conclusion:
7. The name and address of claimant(s) eligible for payment of
compensation:
8. Amount spent on cashless treatment of the victim:

9. The amount of compensation recommended for payment to the
claimant. (In case of more than one claimant the amount each one of
the claimants is eligible for, and the reasons thereof shall be specified):
10. Any other information or records relevant or useful for the settlement
of the claim:
Signature, designation
Seal: of the Claims Enquiry Officer.
Date: