ANNEXURE- VI
Specimen proforma for grant of interim relief to the claimant under section 126 of the Railways Act, 1989.
.I, ___________________________son / daughter / wife / widow of_______________ residing at____________________ having been injured in railway accident hereby apply for thegrant of interim relief for the injury sustained.
I, _________________son / daughter /wife / widow of __________ residing_________athereby apply as dependent for the grant of interim relief on account of the death / injurysustained by Shri / Smt / Kumari __________ son / daughter / wife / widow of Shri / Smt._________________ who died / was injured in the railway accident referred to hereunder.
I understand that the Railway relief so granted will be finally adjusted with the final awardto be made by Railway Claims Tribunal in this case.
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 case of married woman 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 employer of the deceased, if any:___________
6. Brief particulars of the accident indicating the date &place of accident and the name of the train involved_______________________________
7. Class of travel & ticket / pass number to the extent knownon____________
8.Documentary proof of bona fide of the victim / deceased person as passenger of the train on the day of accident/ untoward incident, if available.
9. Journey from______________________________________________
10.Nature of injuries sustained along with medical certificate _____________________________
11. Name and address of Medical Officer practitioner, if any, who attended on the injured/dead and period of treatment ______________________________________________
12. Disability for work, if any caused _______________________________________________
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 interim relief claimed _______________________________________________
17. Bench of RCT where claim has been filed along with O.A. No. &date __________________
18. Proof of dependency, if the interim relief is sought by the dependant of the injured/dead passenger.
19. Any other information or documentary evidence that may be necessary or helpful in the disposal of the claim for interim relief ________________________________________________________
20. Mention the documents, if any, filed along with application I, _______________________solemnly declare that ____________________________________
THE particulars given above are true and correct to the best of my knowledge and belief.
Signature or Left thumb
Impression of the Applicant
Dated _____________
Place______________
Name of Witness and his address
In case of left thumb impression is put by applicant
To
The Chief Comml Manager ( Claims )
South Eastern Railway
14, Strand Road (10th Floor )
Kolkata – 700001
