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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

Title of the case:

PART II

INDEX

_____________________________________________________________________________

Sl. No. Description of documents attached Page No.

_____________________________________________________________________________

1. Application

2.

3.

4.

5.

6.

_____________________________________________________________________________

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:

1. 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-

6 (b) Brief particulars of the untoward incident indicating the date and place of the untoward incident.

7. Class of travel, and ticket/pass number, platform ticket number to the extent known________.

8. Nature of injuries sustained along with medical certificate.

9. Name and address of the Medical Officer/Practitioner, if any, who attended o­n 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 to the train

_________________________________________________________

12. Has any claim 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 to the train or untoward incident, the grounds 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 application.

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: Signature or left thumb impression of the applicant

Place:

(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: Signature of the applicant

Place: Full address:

To,

The Registrar,

Railway Claims Tribunal,

___________________

___________________




Source : North Central Railways / Indian Railways Portal CMS Team Last Reviewed on: 15-01-2015  


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