CASE APPLICATION

Road Accident Compensation Application

Complete the form carefully, attach the required documents and submit your application.

Fields marked with an asterisk (*) are mandatory.

Injured/Dead Detail

Name

Father/Husband Name

Date of Birth

Gender

Religion

Accident & Medical Detail

Injury Type

Work Disability

Accident Detail (Including date/place/Vehicle etc.)

Medical Officer Name

Medical Officer Post

Examine / Treatment Duration

D M Y

Full Address

State

District

Tehsil

Pin Code

Accident Location & Vehical

State

District

Tehsil

Place

Pin Code

First Vehical Number (If Any)

Second Vehical Number (If Any)

Case Details

State ( Police Station )

District ( Police Station )

Police Station

FIR Number

Date of FIR

Court

Case Date

Compensation Amount Related Detail

NOTE : All Detail should be related to the Compensation Amount !

Enter the details only after confirming the compensation amount received from your bank statement.
In case of non-receipt of compensation amount, mention the details of the bank account in which the amount is to be received

Account Number

IFSC Code

Amount Received

Date of Amount Received

Compensation Amount (To Be Received)

Applicant Details

Name

Father/Husband name

Date of Birth

Gender

Religion

Required Documents

FIR ( .pdf Only )

Medical Report ( .pdf Only )

Death Certificate (If any)( .pdf Only )

Injured / Dead Related

Aadhaar Card Front

Aadhaar Card Back

Photo

Signature

Applicant Related

Aadhaar Card Front

Aadhaar Card Back

Photo

Signature

Beneficiary

Family ID (community ID) or ration card which must contain the name of the Deceased/Injured

Number of Beneficiaries

Aadhaar Card Back

Aadhaar Card Front

Passport Size Photo

Bank Passbook ( Nationalized Bank )

INSTRUCTIONS

Copy of the original document related to the case.
Photocopied documents: Above all, the document in 4 copies (signed or thumb printed by the main beneficiary).
After completing the online application, send the hard copy given below by post:
Life Saving Organization National Office
Swami Vivekanand Parisar, Katara Hills,
Bhopal, Madhya Pradesh – 462043
Tel: 0755-4222969, +91-9244966369
E-mail: support@lifesavingorganization.com

Application For Please select the type of claim you are applying for.

I son/daughter/wife/widow of , resident of , District , State , having been injured in a road accident, hereby apply for the grant of interim relief for the injury sustained. I declare that the above information given by me is true to the best of my knowledge and belief; I have not concealed anything. I am aware that if I provide false or misleading information, all benefits received by me will be withdrawn. I son/daughter/wife/widow of , resident of , District , State , hereby apply as a dependant for the grant of interim relief on account of the death of , son/daughter/wife/widow of who died in the road accident referred to hereunder.
I declare that the above information given by me is true to the best of my knowledge and belief. I have not concealed anything. I am aware that if I provide false or misleading information, all benefits received by me will be withdrawn.

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