Format of Affidavit for Death Claim

Format of Affidavit for Death Claim
Format of Affidavit for Death Claim


MVA Petition No…..of _____

1- _____ widow of Late _____
2- _____minor / aged about _____ years son of  _____

Petitioners No.2 through their mother next friend and natural guardian _____  Wd/o Late _____
All residents of _____



1- _____ son of _____

(Driver of the offending vehicle _____ No. _____)

2- _____
(owner of the offending vehicle _____ No. _____)

3- Insurance company, if any, the particulars shall be furnished later on as and when disclosed by the respondents Nos. 1 and 2.
(Insurer of the offending vehicle _____ No. _____)




We, the above-named petitioners being the legal heirs/representatives of deceased _____ son of _____, do hereby apply for the grant of compensation, who died in the roadside vehicular accident caused by the respondent No.1 by driving the offending vehicle _____ No. _____ very _____ and with a high speed Opposite _____, _____ on _____ at about _____.

The necessary particulars in respect of the vehicle, deceased etc. are given herein below:-

1- Name & father’s name of the person deceased – ____son of ____

2- Full address of the person deceased – ____R/o ____

3- Age of the person deceased – ____

4- Occupation of the person died – ____

5- Name and address of employer – ____

6- Monthly income of the person – ____

7- Does the person in respect of whom the compensation is claimed pay income tax, if so, state the amount of tax paid? – ____

8- Place, date and time of accident – The accident took place on ____ at about ____ at ____ within the jurisdiction of ____.

9- Name & address of the police Station in whose jurisdiction The accident took place and the case Was registered – Police Station____ where the FIR No____ dated ____U/s. ____ IPC was got registered against the respondent No.1

10- Was the person in respect of whom the compensation is claimed was traveling in the motor vehicle involved in the accident – ____

11- Nature of injuries sustained – ____

12- Name & address of the Medical Officer, if any, who attended the deceased – ____

13- Period of treatment and expenditure – if any? – ____

14-  Registration No. & type of the vehicle involved in the accident. – ____

15- Name & address of owner of the offending vehicle – ____

16-Name & address of driver of offending vehicle – ____

17- Name & address of the insurer of the offending vehicle – ____

18- Has any claim been lodged with the owner /insurer of the offending vehicle – ____

19- Name & address of the applicants – ____

20- Relationship with the deceased – ____

21-Titlte to the property of the deceased – ____

22-Amount of compensation claimed – ____

23- Whether the claim petition is within time. – ____

24-Any other information that may be helpful in disposal of the claim petition – ____

(i) That the deceased was a _____ man of _____ years of his age and was having a good stout personality and physique and was looking after the petitioners. The deceased was doing the_____ work and he was earning _____/- per month. The petitioner No.1 has lost her life partner while the petitioners No.2 have lost their father and fatherly love and affection in their early age.  All the petitioners are deprived from the love and affection of the deceased. The deceased was providing the food, clothes, and other necessitates of the life to the petitioners and was spending all his earnings on the petitioners. The petitioners were fully dependent on the income of the deceased. There is no earning member in the family of the petitioners as the petitioner No.1 is he house lady and the petitioners No.2 are the minors so none of the petitioner is able to earn for their livelihood. Due to untimely death of the deceased the petitioners have not only lost their family supporter but also they have come at the pointy of starvation as there is no any other earning member in the family of the petitioners. The parents of the deceased had already been died.

(ii) That the respondent No. 1 _____. Thus the respondents No.1 to 3 are jointly and severally liable to pay the compensation to the petitioners.

25-Brief Description of the Accident:
That on _____.
On the statement of _____ son of _____ Caste _____ resident of _____  the FIR No. _____ dated _____ under section _____IPC was registered in the police Station _____

It is, therefore, prayed that the petition of the petitioners may kindly be accepted and an award of _____/- (_____ only) under section _____ of the Motor vehicle act along with interest @ _____% , per annum from the date of accident till the date of realization of the amount in full may kindly be passed in favour of the petitioners and against the respondents jointly and severally with costs of the petition.

It is further prayer that an award of _____/- under section _____ of the M.V. Act, under No Fault liability may also kindly be passed in favour of the petitioners and against the respondents jointly or severally.


Through counsel

_____Advocate, _____


Verified that the contents of our above petition from Para No.1 to 25 are true and correct to the best of our knowledge and belief. The last Para is the prayer before this Hon’ble Tribunal

Verified at _____ on _____


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