CASE APPLICATION

Railway Accident Compensation Application

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

Fields marked with an asterisk (*) are mandatory.

Injured / Dead Details

Name

Father / Husband Name

Date of Birth

Gender

Religion

Journey Details

Train Number & Name

From Station

To Station

Boarding Station

Class

Ticket / Pass Number

Accident & Medical Details

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

Case Details

State ( Police Station )

District ( Police Station )

Police Station

FIR Number

FIR Date

RCT Court

Case Date

Compensation Amount Related Details

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 )

Proof of presense in Train( .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 Complete the Online Application Send Hard Copy Given below By Post –
LSO Legal Private Limited National Office is located at – Swami Vivekanand Parisar, Katara Hills Bhopal Madhya Pradesh – 462043
Tel: 0755-4222969,+919244966369
E-mail: lsolegal369@gmail.com

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 in it Not there.I am aware that if I provide false or misleading information, all the benefits received by me will be withdrawn.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 I am aware that if I provide false or misleading information, all benefits received by me will be withdrawn.

CAPTCHA Answer

Railway Accident Compensation Application

Injured / Dead Details

Journey Details

Accident & Medical Details

Case Details

Compensation Amount Related Details

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

Applicant Details

Required Documents

Injured / Dead Related

Applicant Related

Other Important Documents (Self Attested)

Beneficiary

INSTRUCTIONS