I wish to claim compensation under section 140 of the Motor Vehicles Act, 1988 only.

Or

I wish to make a claim for compensation under the said Act and also in pursuance of the right on the principle of fault.

I,.. .. .. .. ..solemnly declare that the particulars given above are true and correct to the best of my knowledge and belief and that no claim in respect of the said accident has been filed or is pending before any other Court.

Signature or thumb-Impression of the applicant.

[See section 213(3) of the Motor Vehicles Act, 1988]

Date.. .. .. .. .. .. .. .. .. ..

Form COMP. B

[See rule 329(3) of the West Bengal Motor Vehicles Rules, 1989]

Original

No. A.......................

No. .. .. .. .. ..Hospital

Date .. .. .. .. ..

I certify that I have this day.. .. .. .. ..examined.. .. .. .. ..who stated before me that he was injured in motor Vehicle accident on.. .. .. .. ..and I further certify that he was admitted into this hospital on .. .. .. .. .. ..and discharged on.. .. .. .. ..and treated in the O.P.D from .. .. .. .. .. ..to.. .. ... .. ... .. ..

In my opinion the injury or injuries which he has suffered by reason of the accident resulted in -

(a) permanent privation of the sight of either eye or the hearing of the either ear or privation of any member or joint;

(b) destruction or permanent impairing of the powers of any member or joint; or

(c) permanent disfiguration of the head or face.