Name of Legal heirs. PARTICULARS IN RESPECT OF ACCIDENT AND OTHER INFORMATION'S ARE GIVEN BELOW 1. Name and Father's name of the person dead. 2. Address of the person dead. 3. Age Date of birth 4. Sex of the person dead. 5. Place, date of the accident. 6. Occupation of the person dead. 7. Nature of injuries sustained as per medical report. 8. Name and address of the police station in whose jurisdiction accident took place or was registered. 9. Name & address of the claimants and relationship the dead. 10. Name and address of the 3 Medical Officer who attended the dead. 11. Any other information that may be considered necessary or helpful in the disposal of the claims. We do hereby swear and affirm that the facts noted above are true to the best of our knowledge and belief. Signature of the Claimant Male Female FORM -A APPLICATION FOR COMPENSATION FROM SOLATIUM FUND (Clause 81(1)) Published on National Portal of India (india.gov.in) Government of OrissaLaw Department
