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10.
Name and Address of the police Kundapura Traffic Police Station in Crime
station in whose jurisdiction, the No.132/2019
accident took place was
registered
11.
Was the person in respect whom Yes
compensation claimed travelling The petitioner was travelling in a Honda
in the vehicle involved in the Activa Scooter bearing Vehicle Reg.No.KA-
accident?
20-EL-2773 along with his Bharathi Shetty
If so give the name of place of
starting of journey and and was travelling from Kundapura side to
destination Manooru side by wearing
Helmet(Headgear) and was riding the said
scooter in a slow and steady manner by
following all traffic rules
12.
Nature of injuries sustained, As detailed in the Wound Certificate
Continuing affect if any of the Enclosed
said injury, whether it caused
permanent disablement?
13.
Name and Address of the 1)Dr.N.Bhaskar Acharya(Major)
Medical Officer who attended the Consultant Surgeon
injured Dr.N.R.Acharya Memorial Hospital
Koteshwara
Koteshwara Village & Post
Kundapura Tq, Udupi Dt-576222
18.
Name and address of the Driver Damodhara Pai(20 Years)
of the Vehicle S/o.Prakash Pai
R/o.Nandikeshwara Nilaya, Moodugopadi
Gopadi Village& Koteshwara
Post, Kundapura Tq, Udupi Dt-576222
19.
Has any claim been lodged with No
the owner/insurer of the vehicle?
20.
Name and address of the As Detailed in the cause title above
applicant?
21.
Relationship with the injured? Does not arise
22.
Title to the property of the Does not arise
injured?
23.
Amount of Compensation Rs.28,20,000/-
Claimed? And Basis thereof
24.
Whether the report from the Report from the police is annexed and
Police and the report from the report from the registering authority not
Registering Authority have been? annexed as it is not available at present
If so to be annexed? and will be produced during the trail of the
case
25.
Whether the affidavit from the Annexed
Applicant/Witness as per rule
232© are annexed?
26.
Whether documents mentioned Annexed, as detailed in the documents
in Rule 232© are being annexed?
Duly indexed?
4
27.
Any other information that may
be necessary or helpful in the -
disposal of the claim?
III.
That on 04/12/2019 at about 10.15 AM the petitioner was
travelling from Anagalli side to Manoor side in a Honda Activa
Scooter bearing Vehicle Reg.No.KA-20-EL-2773 along with his
wife Bharathi Shetty as the pillion rider and was riding the said
scooter in a slow and steady manner by following all traffic rules
and wearing helmet and when his motor cycle(Scooter)reached
a place Near Kamalamma Kalyana Mantapa , Infront of Nagesh
Tailor House at Koteshwara at that time another motor cycle
bearing Vehicle Reg.No. KA-20-ER-9999 belonging to the 1 st
Respondent ridden by its rider in a very high speed rash and
negligent manner came from the left side and dashed against
the scooter of the petitioner from the front side and due to the
said impact the petitioner along with his wife i.e. pillion rider
and his motor cycle fell down to the road and sustained
grievous injuries as detailed in the wound certificate produced
herewith.
A) That the accident occurred solely due to the high speed, rash
and negligent and careless riding of the rider of the motor
Cycle(Bike) bearing Vehicle Reg.No. KA-20-ER-9999 belonging
to the 1st Respondent, who was riding the said motor Cycle(bike)
in a high speed and in a very rash and negligent, careless
manner violating every traffic rules and without observing the
traffic rules and without proper care circumspection and vigil.
Place: Udupi
Date: - -2020 Advocate for the Petitioner Petitioner
Place: Udupi
Date: -2020 Petitioner
VERIFICATION
Verified at Kundapura on this …… day of May 2020, that the contents
of the above application are true and correct to my knowledge and
belief.
Kundapura.
Date: - -2020 Petitioner
7
Place: Udupi
Date: - -2020 Advocate for the Petitioner
8
AFFIDAVIT
I, Rangayya Shetty, aged about 59 years, S/o.Late Krishnappa
Shetty, residing Sri Ganesh, Herikudru, Anagalli Village & Post, Udupi
Taluk, Udupi Dt., do hereby solemnly affirm and oath as follows:
1) I say that I am the deponent herein and the guardian of the
petitioner in the above case
3) I say that, averments made in the above petition are all true and
correct to the best of knowledge, belief and information.
8) I say that, facts stated herein above are all true and correct.
Place: Udupi
Dated: - -2020 DEPONENT
Identified By Me:-
10
Place: Udupi
Date: - -2020 Advocate for the Petitioner
11
======
Total Rs. 16=00
======
Place: Udupi
Date: - -2020 Advocate for the Petitioner
12
To
R1,
Kiran Nayak (27 Years)
S/o.Krishna Nayak
R/a. Door No.2/35,
Laxmi Damodahara Nilaya
Mundar Mundi , Nanchur Village& Post
Udupi Tq & Dt -576234
Given under my hand and seal of the Court this ……………….. day of
…………………………….. 2020.
To
R2,
The United India Insurance Co.Ltd
Rep by its Present Branch Manager,
Branch Office, Putturu Branch
Prabhu Building, Opp.Aruna Talkies
Main Road, Puttur Village& Post
Puttur Tq, Dakshina Kannada Dt-574201
Given under my hand and seal of the Court this ……………….. day of
…………………………….. 2020.
INDEX
Sl.No Description Pages C.F. Paid
1) Petition with verification Rs.10/-
2) Affidavith
3) Vakalathnama
5) List Of Documents(Originals)
TOTAL
Rs.26/-
Place: Kundapura
Date: - -2020
15