Claim Registration

Agency Name *

Contact Person Name *

Contractor Phone Number *

GST IN *

Full Address *

Agency Email *

Agreement Number*

Agreement Date*

Agreement Amount*

Name of Work*

Zone*

Unit (Division/HQ)*

Department*

Officer of Respondent (Divisional Level)*

Documents (allow pdf only)*

Claimant Claim Amount(in Thousand)*

Claim Full Description*