FORM II
APPLICATION FOR COMPENSATION UNDER SECTION 16 OF THE ACT IN RESPECT OF CLAIMS FOR COMPENSATION FOR DEATH AND INJURY AS A RESULT OF TRAIN ACCIDENT OR UNTOWARD INCIDENT
[See Rule 5 of the Railway Claims Tribunal (Procedure) Rules, 1989]
Application under Section 16 of the Act in respect of claims for compensation arising out of accident to a train.
PART I]
To,
The Registrar,
Railway Claims Tribunal,
____________________
_______________________
Title of the case:
PART II
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Signature of the Applicant
For use in Tribunal’s Office:
Date of filing
Or
Date of Receipt by post
Registration 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 to train or untoward incident hereby apply for the grant of compensation for the injury sustained.
I, ___________________________son/daughter/wife/widow of _______________________ [residing at] _________________________ hereby apply as dependant for the grant of compensation on account of the death/injury sustained by Shri/Kumari/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:
incident, the grounds thereof ____________________
18. Any other information or documentary evidence that may be necessary or helpful in the disposal of the claim ____________________
1. 19. Mention the documents, if any, filed along with application1. Name and father’s name of the person injured/dead (husband’s name in the 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. (a) Brief particulars of the accident indicating the date and place of accident and the name of the train involved
7. (b) Brief particulars of the untoward incident indicating the date and place of the untoward incident.
8. Class of travel, and ticket/pass number, platform ticket number to the extent known________.
9. Nature of injuries sustained along with medical certificate.
10. Name and address of the Medical Officer/Practitioner, if any, who attended on the injured/dead and period of treatment____________
11. Disability for work, if any, caused.
12. Details of the loss of any luggage on account of the accident to the train _______________________
13. Has any claim been lodged with any other authority? If so, particulars thereof _____________________________________________________
14. Name and permanent address of the applicant ____________
15. Local address of the applicant if any
16. Relationship with the deceased/injured _________________
17. Amount of compensation claimed ______________________
18. Where the application is not made within one year of the occurrence of the accident to the train or untoward.
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/loss of luggage which is the subject matter of this application.
Date:
Place:
Signature or left thumb impression of the applicant
(Name of the 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 ______ are believed to be true to the best of my knowledge or the legal advice given to me, and that I have not suppressed any material fact.
Date:
Place:
Signature of the applicant
Full address:
