Business Letter Writing Template : Application For Compensation Claims



This Letter should be written in The Letter-Pad of the Company.



Application Under Section 16 Of The Railways Act In Respect Of Claims For Compensation Arising Out Of Accident To A Train :

Part i Title Of The Case

Part ii Index

S no description of documents attached

Page no

1.

2.

3.

4.

For us in trubunal’s office

Signature of the applicant

…………………………………..

Date of filing or date of receipt by post

Registration no.

…………………………………..

Signature for registrat

Part iii

To,

The railway claims tribunal,

……………………………
……………………………


I, ……………………………….. Son/daughter/wife widow pf ……………. 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/kumari.cshrimati …………… son/ daughter/wife/window 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 (husban’s name in the case of married woman or window.)……………………………….


2. Full address of the person injured/dead ………………


3.age o the person injured/dead ………………………..


4. Occupation of the person injured/dead …………………….


1. Name and address of the employer of the deceased, if any ……………………


2. Brief partuclars of the accident indicating he dte and place of the accident and the name of the train involved………………………


3. Class of travel and ticket/pass number to the extent known………………..


4. Nature of injuries sustained along with medical certificate. ……………..


5. Name and address of the medical officer/practitioner, if nany, who attended on the injured/dead and period of treatment …………………..


6. Disbiliy for work, if any, caused ……………………….


7. Details of the loss of aby luggage on account of the accident ………………….


8. Has any claim been lodged with any other authority:? If so particulars therof …………………


9. Name and eprmanem address of the applicant …………………….


10. Local address of the applicant, if any ………………………….


11. Relationship with the deceased/injured…………………………..


12. Amount of compensation claimed ………………..


13. Where the application is not made within one year of the occurrence of the accident, the grounds thereof. ………………….


14. Any other information or documentary eveiden that may be necessary or helful in the dispoal of the claim. ……………….


15. Mention the documents, if any filed alongwith application. ………………….


I, ………………… solemnly declare that

(a) the partuclars 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, which is the subject mater of the application.


Signature or the thumb-impression of the applicant.


Date ………………
Place ……………..


Name of winteness and his address in case left thumb impression is put b the applicant. …………………………………………….


Verification :


I, ………………….(name of the applicant) s/0, d/o, w/o ………….. Age ………. Resident of ………. Do hereby verify that the contents of paragraphs ………. To …………… are true to my personal knowledge and paragraph ……………. To ……………. Are believed to be true to the best of my knowledge or the legal advice to me, and that i havenot suppressed any material fact.


Singanture of the applicant :


Full address …………………
Date ……………………….
Place …………………………


To,


(address of the railway claims tribunals over west zone)


1. Raiway claims tribunal, mumbai

180, p d’ mello road,
19/t vig wam, mumbai 400 001
(maharashtra state)


2. raiway claims tribunal, ahmedabad

Hari niwas, mani nagar,
Char rasta, ahmedabd 380 008.
(gujarat state)


3. Raiway claims tribunal, mumbai

Presenting officer rct jaipur
D 255/aa devi marg, bni park, jaipur (rajashtan state?)


4. raiway claims tribunal, mumbai


hanbganj railway station campus, hoshangabad road,’near MPSRTC office, Bhopal 462016
(Madhya Pradesh state)

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