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Affidavit Cum Declaration

1. The affidavit details a workplace accident that resulted in the death of Jaglinga Laxman Poojari, who was working as a daily wage laborer at a construction site. 2. He died from injuries sustained after a cement block fell on his head at the site. 3. His employers, M/s Shail Enterprises and sub-contractors, paid Rs. 4,00,000 to his family as full and final compensation for his death.

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2K views5 pages

Affidavit Cum Declaration

1. The affidavit details a workplace accident that resulted in the death of Jaglinga Laxman Poojari, who was working as a daily wage laborer at a construction site. 2. He died from injuries sustained after a cement block fell on his head at the site. 3. His employers, M/s Shail Enterprises and sub-contractors, paid Rs. 4,00,000 to his family as full and final compensation for his death.

Uploaded by

yasin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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AFFIDAVIT CUM DECLARATION

We, 1. MR. LAXMAN BALAPPA POOJARI, Adult, Age 50 Years,


Aadhar No. 8837 0808 7162 2. Anil Laxman Poojari, Adult, Age 25 Years,
Aadhar No. 8804 6447 6089 3. ANITA JAGLINGA POOJARI Adult, Age 25
Years, Aadhar No. 7737 9717 4063 Indian Inhabitant, residing at. Kalimati
Chawl, Road No. 05, Nehru Nagar, Ville Parle (W), Mumbai – 400 056, do
hereby state, take oath & Declare on solemn affirmation as under:-
1
That, my Son / Brother / Husband namely JAGLINGA LAXMAN

POOJARI aged 26 years who was working as a daily wages labour at Hiranandani

Estate project namely Obelia Tower A & B Wing at Patlipada, Thane, with

contractor namely “ M/s Shail Enterprises” Shailesh Amrutlal Chopda and

partners, having their registered office at – 201 Sneh Opp. Sai Baba Temple, M. G.

Road, Kandivali (W) Mumbai – 400 067, who had allotted the work to their Sub –

Contractor namely Khalya Sukya Vadhta, and Balaram Timmer at the construction

site mentioned above.

That, my Son / Brother / Husband namely Jaglinga Laxman Poojari while

working at the abovementioned construction site met with an unavoidable accident

on dated 11.03.2019 by falling of Cement Block on his head and on dated

12.03.2019, my son died at Nanawati Hospital.

That, my Son / Brother / Husband died in the course of employment with

Contractor “ M/s Shail Enterprises” and their Sub – Contractor Khalya Sukya

Vadhta, and Balaram Timmer at at Hiranandani Estate project namely Obelia

Tower A & B Wing at Patlipada, Thane.

That, contractor namely “ M/s Shail Enterprises” Shailesh Amrutlal Chopda

and partners and their Sub – Contractor namely Khalya Sukya Vadhta, and

Balaram Timmer had compensate sum of Amount Rs. 4,00,000 /- (Four Lakhs

2
Rupees Only) to the family members of the deceased JAGLINGA LAXMAN

POOJARI as a lumpsum Full and Final Compensation

Declaration of Compensation Amount paid in the Following manner -

1. Rs. 3,00,000/- : RTGS ______________ on dated


14.03.2019

2. Rs. 1,00,000/- : Cheque No. 420659 through Indian


Overseas Bank, Branch – Borivali (W)
dated on 14.03.2019

That, I / we further states that, I /We had received and accept the said

compensation of Rs. 4,00,000/- from “ M/s Shail Enterprises” Shailesh Amrutlal

Chopda and partners and their Sub – Contractor namely Khalya Sukya Vadhta, and

Balaram Timmer, I / We says that, I / We or any other family members had no

further claim or accusation from my/our part for the claim of Monetary

Compensation from “ M/s Shail Enterprises” Shailesh Amrutlal Chopda and

partners and their Sub – Contractor namely Khalya Sukya Vadhta, and Balaram

Timmer, and I / We or any other family members after receiving the said monetary

compensation will not proceed for any legal proceeding against “ M/s Shail

Enterprises” Shailesh Amrutlal Chopda and partners and their Sub – Contractor

namely Khalya Sukya Vadhta, and Balaram Timmer in any court of law, or will

not approach to any Tribunal, NGO or Trust for the claim of compensation.

3
That, “ M/s Shail Enterprises” Shailesh Amrutlal Chopda and partners and
their Sub – Contractor namely Khalya Sukya Vadhta, and Balaram Timmer had
also promised to pay the amount of Insurance as and when received by them
subject to fulfill the requirement of paper of Insurance Company of Bajaj Allianz
General Insurance Company Ltd. Bearing the Policy No. OG-19-1904-2801-
00000567.

Whatsoever stated hereinabove is true and correct to the best of my


knowledge, belief, and understanding. No part of it is false & nothing material has
been concealed there from. If found incorrect we are liable for action.

Solemnly affirmed at Thane on this 19TH day of March, 2019.

Deponents :

Sr. Name of Deponents Relation with Aadhar Card Signature Photo


no. Deceased No.
MR. LAXMAN SON 8837 0808
1. BALAPPA POOJARI 7162

MR. ANIL LAXMAN BROTHER 8804 6447


POOJARI 6089
2.

MRS. ANITA HUSBAND 7737 9717


3. JAGLINGA 4063
POOJARI

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