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Application form for preferring Compensation Claim


(Claims for Damage/ Shortage/Loss/Non Delivery of Goods/ Parcel /Luggage)

CAUTION: - As per section 149 of the Railways ACT, 1989,if any person requiring compensation from a railway administration for loss, destruction, damage, deterioration or non-delivery of any consignment makes a claim which is false or which he knows or believes to be false or does not believe to be true, he shall be punishable with imprisonment for a term which may extend to three years, or with fine, or with both.

To be filled in by Claim Office 


Received on









Claim no













                         D    D    M   M Y    Y    Y   Y

Whether particulars adequate?



                                                Yes   No

Claim File No


























                   Type  /  Section  / Dealer  /  Dest Stn  ./  Off Code  /   Month  /  Finance



The Chief Comml. Manager (Claims)

South Eastern Railway

14 th Strand Road (10th Floor)………………………………


Dear Sir,

Under Section 106 of Railways Act 1989, I/We prefer a claim on the --------------------------- Railway particulars of which are detailed below .

1. Amount Claimed Rs.










2. Reference No






































3. Party code



4. Name of  claimant     

























5. Postal Address                        

















































Telephone /E-Mail










6.Document of Booking

             Railway Receipt


Parcel Way Bill




(Tick & fill in as applicable)

Luggage Ticket



Soldier Ticket




Document Number:








7. Date of Booking










8. Booking Station
















9.Destination Station
















10. First Via Station















11. Second Via Station















12. Freight                                                                                      Paid



                                                                                                     To Pay



13. Name of Consignor



















14. Name of Consignee



















14A. Is Consignee?           (a) Military (b) Railway Department (c) FCI (d) Government

                                          (e) Govt. Undertaking ( f) Others

                                               (Ticket whichever is applicable)

15.Title of Claimant :(a) Consignor,(b)Consignee,(c ) Endorsed Consignee (d)Insurance Company, (e ) Others

                                                                   ( Tick whichever is applicable)

16. Commodity Booked























        Commodity Code




                 No. of Packages







17. In case of Wagon Load                                       
















                                                         Owning Rly                                            Wagon No                                                               Type

















                                                        Owning Rly                                               Wagon No                                                                Type

















                                                        Owning Rly                                               Wagon No                                                                    Type

                                                                                          ( Ifmore than three, attach separate Sheet)


18.Booked on



                                                            Railway Risk                                         Owner’s Risk                  ( Tick whichever is applicable )

19. Value Declared Rs.












20. Percentage Charges paid?




                                                                                     Yes                                                              No

21. Cause of Claim






                                                         Non – Delivery                                                 Damage by Fire                                 Shortage


(Tick whichever is applicable)







                                                               Breakage                                                     Loss of complete package                        Leakage







                                                                             Damage by wet                                         Damage due to Delay                               Others

22. Details of loss /Shortage / Damage etc. | If loss – state no. of packages / Bags lost






If shortage – State Quantity (Tonnes/ Qtls. / Kgs.)






Whether Rly. has certified the said Loss / shortage / Damage etc.? 




                                                                                                                                                                  Yes                    No

23. Train No. by which dispatched (if know)
















                                                                                                                         D  D          M   M          Y    Y

24.Whether notice of claims under 106 IRA has already been given?




                                                                                                                      Yes                       No

25.If Yes Notice No              




















                                                                                                                                                                            D      D     M       M         Y        Y

26.Full particulars of contents of the damaged packages showing the value of each article.

27 Remarks, if any.

28 Enclosures (Tick the relevant item)

(1) RR/PWB/FSLA/LT/ST/Others (2) Beejuck Bill (Original) (3) Colliery Bill (Original)(4) TDS/Valuation Statement (in Duplicate). (5) Open /Short Delivery Certificate.(6) Assessment Report/Certificate.(7) Letter of Authority.(8) Subrogation & Special Power of Attorney (9) Gate Pass / PDC. (10) Claim Bill.(11) Undertaking by Claimant. (12) Bank Details.(13) Others (Please Specify).

                                                                                                                         SIGNATURE OF THE APPLICANT

Source : South Eastern Railway CMS Team Last Reviewed : 04-09-2013  

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