Room No.-1, Patiala House Courts, New Delhi

APPLICATION FORM FOR REFERRING THE CASE TO LOK ADALAT

1. Title of the case with present

address of the claimant. :

2. Next / Last date of hearing :

3. Name of the Insurance Co :

4. Name of the claimant counsel :

5. Date of Accident :

6. Name of the Insurance Co. Counsel :

7. Vehicle No. :

8. Policy / Cover note No. :

9. Full address of Policy :

10. Whether W.S. on behalf of Insurance

Company has been filed :

11. Details of the Criminal Case :

a) Name of the Court of

Metropolitan Magistrate :

b) F.I.R. No. :

c) Police Station :

d) Under Section :

e) Whether the case is pending

or decided. :

f) Next / Last Date of hearing :

PHOTOCOPIES OF DOCUMENT TO BE ATTACHED

a) Cover note / Certificate of Insurance Company.

b) Copy of charge sheet & F.I.R.

c) Site Plan

d) Driving License of the accused driver and/or its impound slip.

e) Superdarinama of Vehicle involved in accident.

f) MLC /P. M.. Report

g) Proof of age of the injured/deceased.

h) Bills & cash Memos relating to medical expenses,

if any supported by prescription.

(SIGNATURE OF THE APPLICANT)

IMPORTANT NOTE:

1. Application should be in duplicate with one set of documents.

2. Application incomplete in any respect and / or without any of the documents shall not be entertained.

3. Cases negotiated in conciliation shall not be listed in Lok Adalat.

4. Claimants need not apply in those cases where Written Statement on behalf of the Insurance Company has not been filed.