Application for Compensation

Form II

Application for Compensation under section 16 of the Railway Claims Tribunal Act 1987 in respect of Claims for Compensation for Death Injury etc. in a Train Accident read with Rule 5 of the Railway Claims Tribunal (Procedure) Rules 1989

AB ……………………… Claimant

And

General Manager, Railways       Respondent

Index

Description of documents attached      :

Signature of the applicant                    :

For use in Tribunal’s Office                  :

Date of filing                                       :

Registration No.                                 :

Registrar                                                                                                         Signature

In the Railway Claims Tribunal

Before the ……………. Bench

AB                          ……………  Claimant

And

CD/General Manager ………… Railways

………… Respondent

I, ……………. son of …………….. residing at ………………. having been injured in Railway accident hereby apply for the grant of compensation for the injury sustained.

I, ……………. son of ……………… residing at ……………..hereby apply as dependant for the grant of compensation on account of injury sustained by Shri ……………………………… son of ………………………… residing at …………………… who was injured in the railway accident referred to hereunder.

Necessary particulars in respect of the deceased/injured in the accident are given below:

1.  Name and father’s name of the person injured/dead and husband’s name in case of married woman.

2.  Full address of the person injured/dead.

3.  Age of the person injured/dead.

4.  Occupation of the person injured/dead.

5.  Name and address of the employer of the deceased if any.

6.  Brief particulars of the accident indicating the date and place of accident and the name of the train involved.

7.  Class of travel, and ticket/pass No. to the extent known.

8.  Nature of injuries sustained along with medical certificate.

9.  Name and address of the medical officer/practitioner if any who attended on the injured/dead and period of treatment.

10.  Disability for work if any caused.

11.  Details of the loss of any luggage on account of the accident.

12.  Has any claim been lodged with any other authority? If so, particulars thereof.

13.  Name and permanent address of the applicant.

14.  Local address of the applicant, if any.

15.  Relationship with the deceased/injured.

16.  Amount of compensation claimed.

17.  Where the application is not made within one year of the occurrence of the accident the grounds thereof.

18.  Any other information or documentary evidence that may be necessary or helpful in the disposal of the claim.

19.  Mention the documents if any filed along with application.

I, ……………………………. solemnly declare that

(a) the particulars given above are true and correct to the best of my knowledge and

(b) I have not claimed or obtained any compensation in relation to the injury/death which is the subject-matter of this application.

Signature or left thumb

impression of the applicant

Date:

Place:

Name of witness & address in case of left thumb impression is put by the applicant

Verification

I, …………………… son of …………………. aged ……………………… residing at ……………….. do hereby verify that the contents of paragraphs ……………… to ………………… are true to my personal knowledge and paragraphs ……………… to ……………… are believed to be true to the best of my knowledge or the legal advice given to me and I have not suppressed any material fact.

Signature of the applicant

Full address:

Date:

Place:

To

The Registrar

Railway Claims Tribunal

………… Road, Calcutta

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