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MVC / WC /12 AT MACT/WCCR ………………………………….. REF NO:……………………………… NO:………………………………………. ………. DATE:……………………… DATE:…………………………………… …………… SUBMITTED TO:…………………………… TO:…………………………………. …….
PART-1 CHECKLIST OF DOCUMENTS ENCLOSED WITH THIS REPORT
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DESCRIPTION Certified copies of criminal case records A. FIR B. Charge sheet C. Seizure list D. Zimmanama E. Statement of witness recorded under section 161 Cr.p.c F. IMV report G. Post mortem report H. Inquest report I. Medico legal certificate(MLC) Medical case records with clinical history from the hospital Copies of medical treatment bills Copy of bedside ticket from the hospital Disability certificate Statement of eye witness Statement of the injured Notarized statement of the driver of the our insured vehicle Statement of the claimant (for death claims) Statement of the injured claimants For death claims, where the deceased was a salaried person A. Salary slip/certificate from the employer for the month just earlier to the month of death B. Form 16 for last 3 years C. Last IT returns filed prior to death D. Appointment letter (in case the deceased was working in private sector) E. Bank account details of the deceased d eceased person F. Bank statement of the deceased person person for 3 months prior to to the date of accident G. Copy of the PAN card H. Copy of appointment order for employment given given to the th e widow/children under compassionate ground
TICK
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I. Any other document to prove the income with authenticity For death claims, if deceased person was self employed professional /business / contractor A. Balance sheet of the firm/company prior & subsequent to the death of the deceased person B. Salary slip/certificate from the employer for the month just earlier to the month of death C. Copy of the PAN card & Last IT returns filed prior to death D. Bank account details of the deceased person E. Bank statement of the deceased person for 3 months prior to the date of accident F. Copy of licence of the deceased contractor and contract details G. Status of the contracts after the death of the contractor H. Any other document to prove the income with authenticity For the death claims, where the deceased was skilled / semi skilled worker A. Statement of village sarpanch / other persons regarding occupation & income B. Copies of voter ID card of the deceased person and his spouse & parents C. Authentic age proof of the dependent parents, if the deceased was a bachelor For injury claims, where the deceased was salaried person A. Regular monthly salary slip/certificate B. Details of absence/leave from workplace C. Salary slip/ certificate for the period that he/she was on leave/absent D. Certificate of employer for reimbursement of medical expenses Vehicle documents A. Copy of RC with fitness certificate B. Copy of DL of the driver of our insured vehicle duly verified with RTO C. Copy of permit of our insured vehicle duly verified with RTO D. Copy of insurance policy of other vehicle(s) involved in the accident E. Copy of DL of the driver of other vehicle(s) Photographs A. Spot of accident with clarity in road direction, median and surrounding landmark, such as trees, buildings, shops etc B. Claimants (for death claims) C. Injured claimant D. Residence of claimant(s) E. Hospital / nursing home where the treatment was taken by the injured(s) - both inside and outside
Date: investigator
seal and signature of the
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PART – 2(MVC/WC: 1
2 3
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AT
MACT)
a) Date, time & place b) What were the reasons for which the deceased / injured person was at the spot of accident when the accident was occurred? Description of occurrence of accident as per FIR & other sources Accident site plan (sketch to be given regarding position of the vehicle(s) involved in the accident & the victims with clarity in road direction, median and surrounding landmarks, such as trees, buildings, shops etc) Brief facts which either contradict to what is alleged in the claim petition or which have been concealed
1. 2. 3. 4. 5 Name & complete postal address of witness as per section 161 of Cr.p.c 1. 2. 3. 4. 6 Whether the witness of 161 Cr.p.c are known/ related to injured/ deceased? 7 Why the eye witness was present at the spot when accident took place? 8 What action he (they) took after the accident? 9 Name & complete postal address of witnesses not named under section 161 of Cr.p.c 1. 2. 10 How many motor vehicles involved in the accident? (furnish below, the details of all vehicles involved in the accident) Our insured Other vehicle-1 Other vehicle-1 vehicle A. Registration no: B. Make & type of the vehicle C. Insurer’s name D. Policy no E. Period of insurance F. Whether OD claim has been lodged, if yes, please furnish details G. Which vehicle driver is accused as per the charge sheet? 11 Whether the vehicle(s) speed away from the spot after the accident?
Visit us : mp9480212121.blogspot.com Please mention the name & status (as per the list of status appended in item no:16) of the deceased / injured person(s) at the time of the accident 12 Name of the person(s) died at the spot 1. 2. 3. 13 Name of the person(s) brought dead to 1. the hospital 2. 3. 14 Name of the person(s) succumbed to 1. died on……………. injuries after receiving treatment in 2. died on……………. the hospital 3. died on……………. 15 Name of the person(s0 injured 1. 2. 3. 16 Paid driver of Paid driver of Helper of our Helper of Ownerour vehicle other vehicle vehicle other vehicle cumdriver Pedestrian Cyclist Motorcyclist Pillion rider Occupant in car Owner or authorized representative of Fare paying passenger in the load body of goods carried in the vehicle truck/ tractor (if so, please specify quantity & nature of goods being carried) 17 Name & address of the person(s0 who 1. were travelling in the vehicle(s0 2. involved in the accident, but did not sustain any kind of injuries 18 Was it a Hit & run case? 19 Whether the involved vehicle(s) was seized from the spot of the accident? 20 Whether the accused driver(s) arrested from the spot or surrendered subsequently to the police authority? Details of enquiry made in police station 21 Name of the police station 22 FIR no: 23 IPC section as per the FIR & MV act 24 Date, time & place of actual accident 25 Date & time of FIR 26 Distance of police station from the spot of accident 27 Name, status & postal address of the FIR maker 28 Name & address of the witness to the 1.
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2. 3.
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Registration no. of the vehicle(s) whose driver(s) were accused as per the FIR 30 Name of the accused as per the FIR 31 Name of the accused as per the charge sheet, if filed 32 If above mentioned person(s) are different, what are the reasons for such substitution? 33 Date of arrest of the accused driver 34 Date of release of the accused driver on bail 35 Date of seizure of vehicle(s) & relevant documents (please mention the details of the documents seized) 36 Date of release of vehicle(s) & documents on zimmanama 37 Name and cadre of the investigating police official 38 For accident, where offending vehicle was unidentified as per the FIR & subsequently charge sheeted, please furnish the justified reasons on the basis of which the police could ascertain the correct identity of actual offending vehicle 39 Please ascertain & furnish detailed reasons & also genuineness for cases, where filing of FIR is delayed belayed beyond a reasonable period 40. vehicle documents Offending vehicle insured by us Name of the driver Present postal address of the driver with mobile no Is the driver still under the employment of the vehicle owner? What steps taken by you ta assit the
Other vehicle involved
Not applicale
Not applicale
Visit us : mp9480212121.blogspot.com insurance copany to bring the driver to adduce evidence before the tribunal? Driving licence no Issued by Authorized to drive Valid till which date Whether verified with licensing authority Whether genuine or fake Permit no Type of permit Valid till which date Whether verified with transport authority Whether genuine or fake Fitness certificate no Valid till which date 41. details of claimant(s) in case of death claims a. Name, father/ husband’s name, age & relationship with the deceased b. Postal address of the claimant(s) c. Whether the details of the dependants have been correctly mentioned in the petition? If not, what are the discrepancies noticed? d. Could you meet all claimant(s) named in the petition? If not, reasons thereof e. Did they co-operate with you in giving the requisite information? f. For death case of unmarried person, what kind of document was obtained to establish the correct age of the father & mother? 42. Details of deceased person A Name & father’s name of the deceased person B Date of birth or age at the time of accident C What documentary proof obtained for admitting the age of the deceased
Visit us : mp9480212121.blogspot.com D Sex & marital status E Qualification F Occupation 43. Details of income where deceased was salaried employee under government/ private sector A Name of the employer B Designation C Date of appointment D Head wise details of salary drawn in the immediate month preceding the month of death E Income tax & professional tax deduction details F Any specific allowance being drawn which is meant for spending by the deceased himself, such as uniform allowance, conveyance etc G Pan no: H For which year the last IT return filed before the death I Bank account no. and name of the bank & branch J Whether salary was being credited directly in the bank account of the deceased K Was there any abnormal increase in the salary or promotion to higher cadre during the last six months before the death? If so, please give details of employment & income thereof M Furnish the details of benefits claimed by the claimant through personal accident/ mediclaim policies / ESI scheme, if any N Has the widow married again subsequent to the death of her spouse? If yes, please give details 44. Details of income where the deceased was self employed profession, such as doctor, charted accountant, lawyer etc, or businessman/ contractor/ shop owner A Specific occupation B Name of the firm/company, if any C Since when engaged in profession/ business D Designation in the company/firm
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Details of salary, if any being drawn from the company/firm F Income tax & profession tax deduction details G Any specific allowance being drawn which is meant for spending by the deceased himself such as director’s fees, conveyance allowance, incentive etc H Pan no: I For which year the last IT return filed before the death J Whether income claimed on the basis of the individual IT return or on the basis of company/firm? K Bank account no. and name of the bank & branch I Are the business activities of the company/ firm/nursing home/ hospital/ contractors etc, in which the deceased was gainfully associated continuing in the same manner even after the death of the victim. If so, please furnish details 46. Details of income where deceased was a skilled/ unskilled worker A Trade/ specific occupation B Reasonable monthly income on the basis of local conditions C Was it stable round the year or seasonal D From which source, such as village sarpanch, a neighbor, persons in similar occupation & income was established? Did they give it in writing? 47. Details of injured claimant A Name & age of the injured person & father / husband’s name B Name & address of the hospital/ nursing home where he was admitted immediately after the accident and also the name & address of the hospitals/ nursing homes where he was treated subsequently along with no. of beds & whether facilities for surgery is available
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D E
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G I K M O Q S T U
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Was it the nearest hospital from the spot of the accident? if not, please find out the reasons thereof and also provide the details of hospital(s) nearer to the spot of accident Registration no. of the hospitals/ nursing homes concerned Name of the person with address, who brought the injured to the hospital after accident Whether hospital record mentions that the injury is on account of road traffic accident? Date of admission H in 1st hospital Room/ bed no. J Date of admission in 1st hospital Room/ bed no.
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Date of admission in 1st hospital Room/ bed no.
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Comments on genuineness of hospital/ nursing home Billing procedure of the hospital Name of the V doctor & his qualification who treated the injued immediately after the accident Has the injury resulted in permanent partial/ total disability? if so, please give the name & qualification of the doctor who had issued the disability certificate What type of disability suffered? What was the basis of evaluation of disability?
Inpatient registration no. Date of discharge Inpatient registration no. Date of discharge Inpatient registration no. Date of discharge Genuine Manual Name of thye doctor(s) & his/their qualification who treated the injured subsequently
Fake Computerized
Neurological/ orthopedic/ ophthalmic/ ear & Nasal Functional incapacity of organ(s)/ physical/ impairment/ amputation of limbs/ loss of vision/ functional
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Name & address of the employer in case of the injured being a salaried person Aa If so, please give the details of leave availed for treatment and whether salary was paid for the period of leave 47. details of insured A Name & postal address of insured B Occupation of insured C Is he aware of the accident? if so, why did not he inform the insurance company about the accident? D Financial status of the insured with details of immovable properties & vehicles owned by him 48. conclusion A Any other relevant information duly supported by authentic evidence which will establish that either the offending vehicle was not negligent or the contributory negligence of the other vehicle B Your overall opinion on the genuineness of the accident & claimants
Under my seal and signature I am submitting this report in two parts on the basis of findings of investigation conducted by me. I hereby affirm that the contents of this report are true to the best of my knowledge and belief, and that nothing material has been concealed. Signature K.M.Prasanna kumara., LLB,(AIII) “basavanugruha”, Behaind traffic station, APMC qutres no: C-25, Chitradurga-500540 Mobile: 9480212121, Lindline: 08198-212121 e-mail:
[email protected] website: mp9480212121.blogspot.com
