Applicant Full Name
Mobile Number
Aadhaar Number
Type of Injury
Name of injured / dead person
Gender
Age
Marital Status
Address
Nominee Type
Nominee Name
Nominee Relation
Wing
District
Taluka
Range
Village(If Village not exist then enter village name)
Village Name
Captcha
Incident Date
Incident Time
Incident Duration
Incident Place
Bank Name
Account Holder Name
Account Number
IFSC Code
Bank Passbook Copy
Aadhaar Copy