MOTOR T.P.

CLAIMS INVESTIGATION REPORT

IN
MAC CASE NO._____ AT____________

___________________V/s______________

SUBMITTED TO :
The Sr. Divisional Manager,
National Insurance Co. Ltd.,
D.O.-II, Badshah Nagar Chauraha,
Mahanagar, Lucknow
PART-I
CHECK LIST OF DOCUMENTS ENCLOSED WITH THIS REPORT

SI. DESCRIPTION Tick

No.
1. a.FIR
b.Chargesheet
c.Seizurelist
d.Zimmanama
e.Statement of witness recorded under section 161 Cr.PC
f.MVI Report
g. Postmortem Report
h. Inquest Report
i.Medico Legal[injury] Certificate
2. Medical case records with Clinical history from the Hospital
3. Copies of Medical Treatment Bills
4. Copy of Bedside Ticket from the Hospital
5. Disability Certificate, if any
6. Statement of Eye Witness[s]
7. Statement of the Insured
8. Notarised statement of the driver of our insured vehicle
9. Statement of the claimant [for death claims]
10. Statement of the injured claimant[s]
11. For death claims, where the decreased 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 three years
c. Last IT return filed prior to death
d. Appointment letter [in case the deceased was working in private sector]
e. Bank account details of the deceased person
f. Bank statement of the deceased person for 3 months prior to the date of
accident
g. Copy of PAN Card
h. Copy of appointment order for employment given to the widow/children under
compassionate ground
i.Any other document to prove the income with authenticity

12. For death claims, if the 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 for the month just earlier to the month of death, in case,
he was drawing salary from the Company/Firm
c. Copy of PAN Card & Last IT return filed prior to death
d. Bank account details of the deceased
e. Bank statement of the deceased person for 3 months prior to the date of
accident
f. Copy of license 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

13. For death claims, where the deceased was skilled/semi-skilled worker

a.Statement of village Sarpanch/other persons regarding occupation & income

b. Copies of voters’ ID Card of deceased person and his spouse & parents
c. Authentic age proof of the dependant parents, if the deceased was a bachelor
14. For injury claims, where the deceased was a salaried person

a.Regular monthly Salary slip/certificate

b. Details of absence/leave from work place
c. Salary slip/certificate for the period that he/she was on leave/absent
d. Certificate of Employer for reimbursement of medical expenses
15. VEHICLE DOCUMENTS

a.Copy of RC with Fitness Certificate

b. Copy of DL of the driver of our insured vehicle duly verified with RTA
c. Copy of permit of our insured vehicle duly verified with RTA
d. Copy of Insurance policy of other vehicle[s] involved in the accident
e. Copy of DL of the driver of other Vehicle[s]
16. PHOTOGRAPHS

a.Spot of accident with clarity in road direction, median and surrounding

landmarks, such as, trees, buildings, shops etc.
b. Claimant[s] 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
from outside & inside

Dated: Seal signature of the Investigator

 PART-II [MAC CAE NO. ]

1. a. Date, Time & Place of accident 28.7.2014 at about 2:30 PM & Faizabad Gonda
Road, Near Parag Milk Dairy
P.S.- Kotwali Nagar Gonda.
b. What were the reasons for which Deceased person was going to Gonda in his
the deceased/injured person was at the motorcycle where he met with an accident with a
mini bus.
spot of accident when the accident
occurred ?
2. Description of occurrence of accident as On 28.07.2014 Mohd. Ashfaq was going on his
per FIR & other sources uncle’s bike No.- UP32EA-7378 from his house to
Gonda when he hit with a mini bus No.-UP42AT-
4960 at about 2:30 pm near parag milk dairy at
Faizabad-Gonda road and injured badly after which
during his treatment he died on 29.07.2014.
3. ACCIDENT SITE PLAN

[Sketch to be given regarding position of the vehicle[s] involved in the accident & the
victims with clarity a road direction, median and surrounding landmarks, such as trees,
buildings, shops etc].
4. Brief fact which either contradict to what 1.
is alleged in the claim petition or which
have been concealed 2.

3.

4.
5. Name & complete postal address of witness as per Section 161 of Cr. P.C.
1.Mohd. Afzal s/o Ali Hussain resident Wakirganj 2.Puran s/o Shivraj, Resident-
Police station- Wakirganj, Gonda. Subedarpurva, Police station- Kotwalinagar,
Gonda.
3.Pappu s/o Shivraj, Resident- Subedarpurva 4.
Police station- Kotwalinagar, Gonda.

Whether the witness of 161 Cr.P.C. are

known/related to injured/deceased?
7. Why the eye witnesses were present at YES
the spot when accident took place?
8. What action he [they] took after the They take the deceased person to the near
accident? hospital immediately by the help of local people.
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 Two Vehicle
below, the details of all vehicles involved in the accident]
Our Insured Vehicle Other Vehicle-1 Other Vehicle-2
a. Registration No. UP 42AT- 4268
b. Make & Type of the Tata & Mini Bus
vehicle
c. Insurer’s Name NIC
d. Policy No. 55270031136300003031
e. Period of insurance
f. Whether OD claims N.A.
has been lodged. If
yes, please furnish
details
g. Which vehicle drive is
the accused as per
the charge-sheet? N.A.

11. Whether the vehicle[s] speed away from the spot N.A.
after the accident?
Please mention the name & status [as per he 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 the 1.Mohd. Ashfaq
hospital. 2.
3.
14. Name of person(s) succumbed to injuries 1. Died on:
after receiving treatment in the hospital. 2. Died on:
3. Died on:
15. Name of the person(s) injured 1.
2.
3.
4.
16. Paid driver Paid driver of Helper of our Helper of Owner-cum-
of our vehicle other vehicle vehicle other vehicle Driver
Pedestrian Cyclist Motorcyclist YES Pillion rider Occupant in car
Owner or authorized representative of goods carried in the vehicle [if Fare paying passenger
so, please specify quantity & nature of goods being carried] in Bus or taxi or auto
Employee travelling in Unauthorised passenger in Goods Workers travelling in the
employer’s vehicle carrying vehicle load body of tuck/tractor
17. Name & address of the 1.N.A.
person[s] who were travelling
in the vehicle[s] involved in the 2.
accident, but did not sustain
any kind of injuries
18. Was it a ‘Hit & Run’ case? YES
19. Whether the accused driver[s] arrested N.A.
from the spot of the accident?
20. Whether the accused driver[s] arrested
from the spot or surrendered N.A.
subsequently to the police authority?

DETAILS OF ENQUIRY MADE IN POLICE STATION

21. Name of the Police Station Kotwali Nagar Gonda
22. FIR No. & Cr. No. 304/14 & 547/14
23. IPC Sections as per the FIR & MV Act 279/304
24. Date, Time & Place of actual accident 28.07.2014 at 2:30 PM

25. Date & Time of FIR 29.07.2014 at 3:10 PM

26. Distance of Police Station from the spot of 3 KM.
accident
27. Name, Status & Postal address of the FIR
Mohd. Afzal s/o Late Ali Hussain, Residence-
Maker Wazirganj Market, Police station- Wazirganj,
Gonda.
28. Name & address of the witness to the 1.
Inquest Report
2.

3.
29. Registration No. of the vehicle[s] whose UP42AT- 4960
driver[s] were accused as per the FIR
30. Name of the accused as per the FIR N.A.
31. Name of the accused as per the Charge- Surendra Prasad Pathak s/o Ramdutt Pathak
sheet, if filed Residence- Paraspur, Police station- Kudwar,
Sulatanpur.
32. If above mentioned person[s] are different, N.A.
what are the reasons for such substitution?
33. Date of arrest of the accused driver N.A.
34. Date of release of the accused driver on 20.08.2014
bail
35. Date of seizure of vehicle[s] & relevant 29.07.2014
documents[please mention the details of
the documents seized]
36. Date of release of vehicle[s] & documents 21.08.2014
on Zimmanama
37. Name and cadre of the Investigating Police S.I. Udayraj Nishad, Police station-
Official Kotwalinagar, Gonda.
38. For accidents, where offending vehicle was
unidentified as per the FIR & subsequently N.A.
charge-sheet, 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 N.A.
& also genuineness for cases, where filing
of FIR is delayed beyond a reasonable
period.
40. VEHICLE DOCUMENTS
Name of the driver Surendra Pratap S/O
Ramdutt
Present postal address of the Village- Paraspur
driver with mobile no. Police station- Kudwar

Is the driver still under the Yes

employment of the vehicle
owner?
What steps taken by you to assist N.A.
the insurance company to bring
the driver to adduce evidence
before the Tribunal?
Driving license no. S-435/STR/84
Issued by Licensing Authority
Sultanpur
Authorized to drive HGVFLGV
Valid till which date 30.11.2012 to 29.11.2015
Whether verified with licensing Licensing authority
authority Sultanpur
Whether genuine or fake N.A.
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 CLAIM[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 the claimant[s] named in the
petition? If not, reasons thereof
e. Did they cooperate 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?
41. DEATAILS OF DECEASED PERSON
a. Name &Father/Husband’s name of the deceased Mohd. Ashfaq s/o Late Ali
person Hussain.
b. Date of birth or age at the time of accident 18 years
c. What documentary proof obtained for admitting the
age of the deceased
d. Sex & Martial Status Male & Unmarried
e. Qualification
f. Occupation Selling biscuits in Mumbai
42. DETAILS OF INCOME WHERE DECEASED WAS SALARIED EMPLOYE 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 & Profession tax deduction details
f. Any specific allowance being drawn which is meant for
spending by the deceased himself, such as, uniform
allowance, conveyance allowance 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, furnish complete details.
l. Whether the widow of the deceased person gainfully
employed by virtue of compassionate ground? If so,
please give the details of employment & income
thereof
m. Furnish the details of benefits claimed by the Claimant
through Personal Accident/Medi-Claim Policies or 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 DECEASED WAS SELF EMPLOYED PROFESSIONAL SUCH AS
DOCTOR, CHARTERED 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
e. 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 bank & branch
l. Are the business activities of 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.
45. 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,
neighbours persons in similar occupation, the
authenticity of the occupation & income was
established? Did they give it in writing?
46. DETAILS OF INJURED CLAIMANT
a. Name & age of the injured person &
Father/Husband’s name
b. Name & address of the Hospital/Bursing 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
c. 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.
d. Registration No. of the Hospital/Nursing Homes
concerned.
e. Name of the person with address, who bought the
injured to the hospital after accident
f. Whether Hospital record mentions that the injury is
on account of road traffic accident?
g. Date of admission h Inpatient Registration
st
in 1 Hospital No.
i. Room/Bed No. j Date of discharge
k. Date of admission l Inpatient registration
nd
in 2 Hospital No.
m. Room/Bed No. n Date of discharge
o. Date of admission P Inpatient Registration
rd
in 3 Hospital No.
q. Room/Bed No. r Date of discharge
s. Comments on genuineness of hospital/nursing Genuine Fake
home
t. Billing procedure of the Hospital Manual Computerised
u. Name of the doctor v Name of the Doctor[s]
& his qualification & his/their
who treated the qualification who
injured immediately treated the injured
after the accident subsequently
w. 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
x. What type of disability suffered?
y. What was the beasis of evaluation of disability
z. Name & address of the employer in case of the
injured being a salaried person. If so, please give the
details of leave availed for treatment and whether
salary was paid for the period of leave
47.DETAILS OF OUR INSURED
a. Name & postal address of the insured
b. Occupation of the 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 detail 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 :