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Public Liability Insurance Act, 1991 FORM I : Form of Application for Compensation Shri/Shrimati/Kumari son of/daughter of/Widow* of Shri _____________________ who died/ had sustained injuries in an 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. Place, date and time of the accident 6. Occupation of the person injured/ dead 7. Nature of injuries sustained 8. Name and address of police station in whose jurisdiction accident took place or was registered 9. Name and address of the medical officer/ practitioner who attended on the injured/dead 10. name and address of the claimant/ claimants 11. Relationship with the deceased 12. 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.    |
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