ANNEXURE- III
FORM II
Application under Section 16 of the Act in respect of claims for compensation arising out of accident to a train.
PART I
Title of the case: Name of the applicant ---------------- Applicant / s
vs.
U.O.I through G.M. / ------------- Respondent
PART II
INDEX
S. No Description of documents attached Page No.
1. Railway report, if any.
2. G R P S’s report
3 Railway ticket or authority to travel.
4.Death Certificate
5 Post-mortem report.
6 Legal heir certificate
7. Medical certificate, in case of injury
Signature of the Applicant
,Date of filling
For use in Tribunal’s office Or
Date of receipt by postRegistration No.
Signature for Registrar
PART III
To
The Railway Claims Tribunal.
I._________, son / daughter / Wife / Widow of ________________ residing at__________ having been injured in railway accident hereby apply for the grant of compensation for the injury sustained.
I. _________son / daughter / window of ___________ residing at______________________hereby apply as dependent for the grant of compensation on account of the death / injury/ sustained by Shri / Kumar / Shriman/ Shrimati______________ son / daughter / wife / widow of Shri / Shrimati_________ who died / 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 (husband’s name in the case of married women or widow.):
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 employed 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 number, to the extent known:
8. Name of injuries sustained along with medical certificate :
9. Nature and address of the Medical Officer/ Practioner, if any who attended 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 claims 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, thegrounds 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 applicationI, _______________ _______solemnlydeclare that:
a) the particulars given above are true and correct to the best of any knowledge and
b) I have not claimed or obtained any compensation in relation to the injury / death ,whichis the subject matter of the application.
Signature or the thumb –impression of applicant
Date----------
Place--------
Name of witness and his address in case left thumb Impression is put by the applicant
VERIFICATION
I, ___________________(name of the applicant) S/o, D/o, W/o_______________________ _____________________
Age__________________resident of_______________ Do hereby verify that the contents of paragraphs to are true to my personal knowledge and paragraphs _ to _ arebelieved to be true to the best of my knowledge or the legal advice given to me and that I have not suppressed any materials l fact.
Signature of the applicant
Full address
Date:
Place:
To
The Registrar,
Railway Claims Tribunal,
