CHANDIGARH ADMINISTRATION FORM OF APPLICATON FOR COMPENSATION FROM SOLATIUM FUND I,Son of/daughter of window of ShriResiding atHaving been grievously injured in motor vehicle accident hereby apply for grant of compensation for th e grievous injuries sustained. Necessary particulars in respect of The injury sustained by me are given below:- Son of/daughter ofWindow of Shrihereby apply as legal representative/agent for the grant of compensation on account of death/injuries sustained by Shri/Shrimati/KumariSon of /Widow of /daughter of Shriwho had died/had sustained injuries in motor vehicle accident on atParticulars in respect of accident and other information are given below:-1. NameFather's NamePerson injured (husband's Name in Case of Married women or widow) 2. Address of the person injured/dead3. AgeDate of Birth4. Sex of the person injured/dead 5. Placedateand time of the accident.6. Occupation of the person injured/dead7. Nature of injuries sustained8. NamAddress of the police state in whose Jurisdiction accident took place or was registered.9. NamAddress of the Medical Officer/Practitioner Who attended on the injured/dead 10. NameAddress of the claimant /claimants11. Relationship with the deceased12 Any other information that May be considered necessary Helpful in the disposal of the claimI hereby swear and affirm that all the facts noted above are true to the best of my knowledge and belief SIGNATURE OF THE CLAIMANT REGISTER OF DOCUMENTS REQUIRED FOR SOLATIUM SCHEME/ MACT CASES (TO BE MAINTAINED BY INCHARGE VICTIM ASSISTANCE CELL, SSP/UT OFFICE) List of Columns of the Register1. S.No.2 FIR No3.Police Station4. NameAddress of deceased/injured5. NamAddress of next of kin(where applicable)6. Documents Received from Police Station 7. Diary of receipt of documents from Police Station.8. Diary No.Date of dispatch of documents to victim.9. Remarks (Confirmation of receipt of documents, Additional assistance required by victim etc.)
