Position Nov /2019

APPLICATION FOR COMPENSATION CLAIM

(APPLICATION FOR COMPENSATION CLAIM FOR DEATH/INJURY ETC.IN ACCIDENT TO TRAIN OR
UNTOWARD INCIDENT)

TO
The Register,
Railway claims Tribunal,
…………………………………………………………………….
…………………………………………………………………….
I,……………………………………………………………………. Son/daughter/wife/window of………………… (Residing at)
…………….having been injured in accident to a train or untoward incident hereby apply for the grant of
compensation for the injury sustained.

I,…………………………………………………………………….. Son/daughter/wife/window of ……………………..(residing

at)………………………………………. Hereby apply as a dependent for the grant of compensation on account of
the death/injury sustained by Shri/Kumar/Srimati………………………………………………………………………………..
Son/daughter/wife/window of Shri/Srimati……………………………………. Who died/was injured in accident to
train or untoward incident referred to hereunder.
Necessary particulars in respect of t he deceased/injured in the accident or untoward incident are given
below:-
1.Name and father’s name of the person injured/death (husband’s Name in the case of married women
or window)
2. Full address of the person injured/dead.
3. Age of the person/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
evolved:
(b) Brief particulars of the untoward incident indicating the date and place of the untoward incident:
7. Class of travel and ticket/pass/Platform Ticket number, to the extent known.
8. Name of injuries sustained along with Medical certificate.
9. Name and address of the Medical Officer/Parctitioner, if any who attend on the injured/dead and
period of treatment.
10. Disability for work, if any , caused:
11. Details of the loss of any luggage of 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 occur rence of the accident/to the Train or
untoward incident the grounds thereof:
18. Any other information or documentary evidence that may be necessary of help 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 is relation to the injury/death/loss of luggage which is the subject matter of
this application.
Signature or thumb impression of the applicant

Date……………………
Place…………………..
Name of witness and his address in
Case thumb impression is put by applicant.

I …………………………………………………………………………………. (Name of the applicant) Son/daughter/wife of

……………………………….. Age………………………….. Resident of ……………………………….. Do hereby verify that the
contents of 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 or thumb impression of the application
Full address.
Place:………………………….
 APPLICATION FOR COMPENSATION CLAIM

NAME OF THE WITNESS AND HIS ADDRESS IN CASE LEFT THUMB IMPRESSION IS PUT BY APPLICANT.
I,______________________( Name of the applicant) S/o.,W/o_____________ Age _________________
Resident of ________________________ do hereby verify that the content 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.

Signature of the applicant

Date_________________________ Full address.
Place_________________________

_____________________________________________________________________________________

To
The Register
Railway Claims Tribunal,
Form –II
Application under Sec. 16 of the Act in respect of claim 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.
2. Signature of the applicant
____________________________
For use in Tribunal’s Office Date of filling or date of Receipt by
Registration No.
Signature for Register
 Application for Compensation Claims
APPLICATION FOR PREFERRING COMPENSATION CLAIMS FOR
THE LOSS,DESTRUCTION DAMAGE ,DETERIORATION OR NON
DELIVERY OF GOODS OR PARCELS CARRIED BY RAILWAY
Letter No: Dated __________

To,

The Chief Commercial Manager,(claims)

Northeast Frontier Railway, Maligaon
Guwahati - 781011.

Dear Sir,

Sub : Claims for compensation : Invoice/Railway Receipt/Parcel Way Bill/Luggage

Ticket No._________from _______ to _______

Under Section 106 and 192 of the Railways Act, 1989, I prefer a claim on the
______________________________Railway, particulars of which are detailed
below:-

1. From _______________(Station) to ___________(Station) via _____________

2. Invoice and Railway Receipt/Parcel Way Bill/Luggage Ticket No.

______________________ dated ____________________

3. No. of packages and description of consignment booked as shown in the Railway

Receipt/Parcel Way Bill/Luggage Ticket _____________________

4. Name of consignor _______________________________

5. Name of consignee ________________________

6. Date of delivery _________________

7. Details of shortage, damage or loss _______________________________

8. Full particulars of the contents of the missing or damaged package/packages

showing the value of each article packed therein
(short or open delivery certificate, if any, should be enclosed) _____________

9. The amount claimed and how it is arrived at (The original trade invoice or other
proof of the value of the goods together
with a copy should be enclosed) __________

10. Power of Attorney/ Letter of Subrogation, if claims are preferred by the authorized
person or agent on behalf of the claimant, should be enclosed.

11. In the case of complete non-delivery, the relevant original Railway Receipt &
Partial Delivery Certificate in the case of part/non-delivery should be enclosed.

12. Bank details________________________.

13. Amount claim Rs. ______________________.

14. Other remarks, if any ___________

Yours faithfully,

(Full Name and Address of the

consignor/
recorded consignee/endorsed
consignee)

Encl:-

1. Original Beejuck together with a copy.

2. Valid power of Attorney on stamped paper of the appropriate value (if claim
preferred by authorized person/claim agent).
3. Valid Power of Attorney and Letters of Subrogation if claims are preferred by the
Insurance Company.
4. Original Railway Receipt or Partial Delivery Certificate in case of non-delivery/
partial delivery or certified copy thereof in case original Railway Receipt is lost
from the custody of the party.
5. Short or open delivery certificate.
6. Other relevant documents, if any.
7. Bank details.

 
 APPLICATION FOR REFUND OF FARE
 
 The Chief Commercial Manager (Refunds),

  Sir,
  Sub: Claim for refund of Fare on Ticket /PNR No. .............................
1. The TDR was issued on cancellation of the above mentioned tickets at ………..................
…….Railway Station.
Reasons for cancellation of journey……………..........................................................…………….
2. ……
3. Name of passengers for whom the ticket was issued.
1…..........................................
2…..........................................
3…..........................................
4…..........................................
5…..........................................
6…..........................................
4. Out of the above persons, the persons at Sl.Nos……….………..…......to………………….not
travelled from ………................... ...............….station to …….........................................….station
Additional information, if any……………………………………………………………………….
5. ……
6. I request that the refund due under the rules, may please be sent to me at my following address.
Name of the Railway Station serving my place of residence
is……………………………………………………..
7. Preferable mode of payment. Station pay order / cheque / money order /: (Tick/mark any one).
  Full postal address : ………………………………......... (in clear block letters)
 Signature of claimant: ……………………………………
Name (in block letters) : …………………………..…….
Date : ……………
 

TICKET DEPOSIT RECEIPT

  (TDR)
  PASSENGER FOIL Chief Commercial Manager
Particulars of Ticket Full postal Address of
Surrendered for cancellation (Refunds) of TDR issuing
  Zonal Railway
  No.
  Date:……..…………Time:……………
1. Journey ticket PNR No…………………………
2. Class:………………………….
3. Train No……………………
4. Date of journey:………………….
5. Validity of ticket: Station from:…………………Station to…………………… station   
via……………………………
6. No. of passengers………………….
7. Supplementary charge ticket/Excess Fare Ticket/Guard Certificate No…………………
8. Reservation Ticket No………………………………..
9. Reservation status:…………………………..
10. Total Charge (in words): Rs………………………
11. Reasons for not granting refund at the station:
………………………………………………………….…
………………………………………………………………………………………………………….
 
  Received TDR Signature of Station
Manager
   
Depositor’s Signature                                                                                                          Station
 Stamp
  Guidelines for Passengers:
1. The passenger is required to send an application for refund (in the application form) to the Chief
Commercial Manager (Refunds) at the address printed on the top of this TDR. The receipt, in
original, must be returned. The application must reach the concerned refund office at the earliest,
but not later than 90 days from the date of journey.
2. The certificate issued by TTE/Conductor for lower class travel, AC failure, less number of persons
travelling etc. are also required to be enclosed in original with the application.
3. It will be in the interest of passenger to either hand over the application or by registered post and
keep a copy of this receipt and other documents.
4. Refund is granted through station pay order (to be encashed at station) or Money Order or Crossed
Cheques. However, Money Orders and Crossed Cheques are issued to persons who are residing
within as well as outside the jurisdiction of refund granting railway. On receipt of pay order, the
passenger should approach the counter of nominated station for encashment within the stipulated
period along with proof of his/her identity such as identity card/Driving Licence/Passport/Ration
Card etc. In case the applicant wants to collect money through his/her representative, an appropriate
authorisation should be made and the authorised person should carry proof of identity at the time of
encashment
 FORMAT FOR PREFERRING CLAIMS FOR REFUND OF FREIGHT OVERCHARGE OF GOODS OR
PARCELS CARRIED BY RAILWAY.
Letter No……………………………… Date:……………………………
To,
The Chief Commercial Manager, (Claims)
Northeast Frontier Railway, Maligaon
Guwahati: 781011

Dear Sir,
Sub: Claims for refund of freight overcharge of goods or Parcel:
Invoice/Railway Receipt/parcel Way Bill No……………………..
From …………………… To……………………………………..

Under Section 106 (3) of The Railway Act, 1989, I prefer claim for refund of freight overcharge, particulars of
which are detailed below: -

1. Station from………………………… Station to……………………… Station via……………………………………………

2. Invoice and Railway Receipt/Parcel Way Bill/ Luggage Ticket No……………………….. Date……………..
3. Description of consignment booked as shown in the Railway Receipt/Parcel Way
Bill……………………………………………………………………………….
4. Name of the consignor………………………………………………………………………………………………………………..
5. Name of the consignee……………………………………………………………………………………………………………….
6. Name of the endorsed consignee, if any…………………………………………………………………………………….
7. Delivery Station………………………………………………………. Delivery Date…………………………………………..
8. Undercharge Amount……………………………………………… Undercharge paid date……………………………
9. Undercharge paid at Station……………………………………... Freight Amount…………………………………….
10. Freight collected at station………………………………………… Freight payment date…………………………..
11. Penal charge amount…………………………………………………. Penal charge date………………………………..
12. Penal charged at station……………………………………………… Reweightment at station…………………….
13. Reasons/ ground for claiming refund of freight overcharge i.e.
a) Error in distance b) rates c) classification d) weight e) description f) calculation etc. to be
mentioned………………………………………………………………………………………………………
14. Money receipt No…………………………………………………….. Date……………………………………………………….
15. Mode of payment……………………………………………………………………………………………………………………….
16. Bank details………………………………………………………………………………………………………………………………..

Yours faithfully,

(Full name and address of the consignor/

recorded consignee/ endorsed Consignee)

Encl:
1. Copy of Railway Receipt/ Parcel Way Bill/ Luggage Ticket.
2. Valid Power of Attorney on stamp paper of the appropriate value (if claim preferred by authorized
person/claim agent).
3. Disclaimer Certificate from the Consignor/ consignee/ Endorsed Consignee as the case may be in the
form of Affidavit.
4. Valid Power of Attorney and Letters of subrogation, if claims are preferred by Insurance Company.
5. Original Money Receipt.
6. Other relevant documents, if any.