APPLICATION FORM FOR PREFERRING COMPENSATION CLAIM
(Claim for Damage/Shortage/Loss of Goods/Parcel /Luggage)

To Be filled in by claim office Whether Particulars Yes No Adequate
Received on : // CLIPS NO:
Claim File Number : / / // / / Type / Section / Destination Station / Dealer / Case No. / Month / Year
The Chief Claims Officer,
Northern Railways,
N.D.C.R Building,
State Entry Road,
New Delhi-110 055
Dear Sir,
Under Section 106 & 192 of Railways Act. 1989,I/we prefer a Claim on the Northern Rly, Particulars of which are detailed below:-
1.Amount Claimed Rs.
2.Reference No.
3.Party Code Dated
/
/
D D M M Y Y
4.Name of Claimant
5.Postal Address:
City State
Pin Tel Off Tel .Res
6.Document of :Railway Receipt :
Booking
: Parcel Way Bill:
:FSLA:
:Luggage Ticket :
:Others:
7.Date of Booking
/
/
D D M M Y Y
8.Booking Station
9.Destination Station
10.First Via Stn.
11.Second Via Stn.
12.Freight Paid
ToPay
13.Name of Consignor
14.Name of Consignee
14A Is Consignee?
a)Military Yes No
b)Railway Department Yes No
15.Title of Claimant : Consignor/
: Consignee/
: Endorsed Consignee (Tick Whichever is applicable)
: Insurance Company
: Others /