To,

The Secretary DHCLSC, New Delhi.

Sub: Application to refer pending MAC Appeal No. ………………... title as ...... to Lok Adalat.

Sir,

The claimant/ insurance company in the abovementioned matters wants to settle the case in Lok Adalat. As per Claimant/Insurance Company the grounds of enhancement/reduction of compensation are on following heads:

Grounds of enhancement of compensation Approximate Amount Sr. No.

1. Multiplier

2. Pecuniary/non-pecuniary damages

Loss of working capacity in relation to 3. disability

4. Any other head

TOTAL

Pending connected Appeal/ case, if any......

DECLARATION

Applicant/ claimant further declare that the above said particulars are true and correct to the best of his knowledge.

Date: ……………….. (Signature of Claimant/Insurance Co./Counsel)