The General Insurance Corporation shall prepare and place an annual report on the working of the scheme before the Standing Committee, and also forward a copy to the Central Government.
Form I
[Clause 20(1)]
Form of Application for Compensation from Solatium Fund
I_________________________________________ son of/daughter of/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/agent for the grant of compensation on account of death/injuries sustained by Shri/Shrimati/Kumari ____________________ son of/widow of/daughter of Shri ___________________ who died/had sustained injuries in a motor vehicle accident on__________ at______________________. Particulars in respect of the accident and other information are given below:
1. Name and father's name of person injured (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.
Form II
[Clause 20(i)]
Discharge Receipt
ANNEXURE
SANCTION ORDER NO.
Dated:
Received with thanks from_______________________________Insurance Co. Ltd. sum of Rs ______________________ being the compensation under hit and run provisions of the Motor Vehicles Act in full and final settlement of my claim for the accident occurred to me/to the deceased person______________________ (name of deceased) on_______________________ (date of accident) at ______________________ (name of place).
Signature on revenue stamp by beneficiary/victim
WITNESS:
Form III
[Clause 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 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 reasons for coming to that conclusion:
7. The name and address of claimant(s) eligible for payment of compensation:
8. 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 and the reasons thereof shall be specified).
9. Any other information or records relevant or useful for the settlement of the claim.
Signature, designation of the Claims Enquiry Officer.
Seal:
Date:
Form IV
[Clause 22(1)]
Serial No. ___________
Claims Settlement Commissioner
District ____________________
ORDER
I hereby sanction Rs 8500/2000 (Rupees Eight Thousand Five Hundred only)/(Rupees Two Thousand only) as compensation in respect of the death of _________________(Name of deceased)/grievous hurt to ____________ (Name of the injured) resulting from hit and run motor accidents which took place at _______ (Name of place) on _____ (Date) to Shri/Shrimati/Kumari ____________________ as the legal representative of the deceased (_____________________________) or to___________________(Name of injured).
Signature
Claims Settlement Commissioner
CC to:
1. Office of the Insurance Company
2. The Claimant
3. Motor Vehicles Accident Claims Tribunals
4. Claims Enquiry Officer
5. General Insurance Corporation of India, Churchgate, Bombay-400 020.
Form V
[Clause 20(1)]
(Under Section 162 of the Motor Vehicles Act, 1988)
I/We__________________ as legal representative(s)/of the deceased/injured _________________ hereby give undertaking that I/We shall refund the amount of compensation awarded to me/us under sanction order No. ________ dated________ by the Claims Settlement Commissioner ______________ to the insurer in case I/We/am/are awarded any other compensation or amount in lieu of or by way of satisfaction of a claim for compensation in respect of death or grievous hurt to__________________ under any other provisions of the Motor Vehicles Act, 1988 or any other law for the time being in force or otherwise.
Signature of the legal representative of the deceased/injured person.