FORM 1 FORM OF APPLICATION FOR COMPENSATION

FORM 1 FORM OF APPLICATION FOR COMPENSATION

Shri/Shrimati/Kumari* ________________________________________________ Son of/daughter of/Widow* of Shri _________________________________________ died/had sustained- injuries in an accident on __________________________________ accident and other information are given below :-

1. Name and Father's name of person injured/dead (husband's name in case of married woman or widow)

2.Address of the person injured/dead.

3.Age ___________ Date of Birth __________

4.Sex of the person injured/dead:

5.Place, date and time of accident:

6. Occupation of the person injured/dead:

7. Nature of injuries sustained:

8. Name and Address of Police Station in whose jurisdiction accident took place or was registered:

9. Name and Address of the Medical Officer/Practitioner who attended on the injured/dead:

10. Name and address of the Claimant/ claimants:

11. Relationship with the deceased: who particulars in respect of

12.Any other information that may be considered necessary or helpful in the disposal of the claim:

I hereby swear and affirm that all the facts noted above are true to the best of my knowledge and belief.

SIGNATURE OF THE CLAIMANT ----------------------------------------------------------------- * Strike out whichever is not applicable