APPLICATION FROM 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 D D M M Y Y Y Y | Whether particulars adequate? | | |
Yes No Type / Section / Dealer / Dest Stn ./ Off Code / Month / Finance |
The Chief Comml. Manager (Claims)
South Eastern Railway
14 th Strand Road (10th Floor)………………………………
Kolkata-1………………………………..
Dear Sir,
Under Section 106 of Railways Act 1989, I/We prefer a claim on the --------------------------- Railway particulars of which are detailed below .
| 6.Document of Booking | Railway Receipt | |
| FSLA | | (Tick & fill in as applicable) |
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)
| 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)
Railway Risk Owner’s Risk ( Tick whichever is applicable )
| 20. Percentage Charges paid? | | | |
Yes No
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 | | | | | | | | | | | Dated | | | / | | | / | | |
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
