Air India Flight AI171, Ahmedabad to London Gatwick, 12 June 2025
QUESTIONNAIRE
The following information will facilitate Air India Limited in processing the advance payments and
determination of the final compensation arising out of the death of a passenger in Flight No. AI171
on 12th June 2025. This form, duly filled in along with the necessary supporting documentation,
may be submitted to Air India via email to
compensation.ai171@airindia.com. Kindly note that
an advance compensation of Rs. 25 lacs** will be paid at this stage which shall be adjusted against
the final compensation payable.
I. Personal information about the passenger
1. First name, family name: ___________________________________________________
2. Date of birth: ____________________________________________________________
3. Place of birth: ___________________________________________________________
4. Sex: male female other (please mark with a cross)
5. Marital status: ___________________________________________________________
6. Nationality: _____________________________________________________________
7. Residential Address:______________________________________________________
8. Please enclose a copy of the birth certificate of the passenger, or any other alternate
proof of age (such as passport, Aadhar Card, etc.)
II. Information about the family members who were related to the passenger
Please kindly provide us with details concerning the family members of the passenger [e.g.:
wife or husband, parent, step-parent, grand parent, brother, sister, half-brother, half-sister,
child, step-child, grand-child.]
Please also provide us with copies of legal documents confirming relationship (e.g.: birth
certificates, marriage certificate, passport, etc) in respect of the below mentioned persons.
1. First name, family name:___________________________________________________
Date of birth: ___________________________________________________________
Address/Telephone:
_______________________________________________________________________
Relationship to the passenger:
_______________________________________________________________________
Email Address: ______________
Financially Dependent on passenger - Yes/ No
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2. First name, family name:___________________________________________________
Date of birth: ___________________________________________________________
Address/Telephone:
______________________________________________________________________
Relationship to the passenger:
________________________________________________
Email Address: ______________
Financially Dependent on passenger - Yes/ No
3. First name, family name:___________________________________________________
Date of birth: ___________________________________________________________
Address/Telephone:
_______________________________________________________________________
Relationship to the passenger:
________________________________________________
Email Address: ______________
Financially Dependent on passenger - Yes/ No
4. First name, family name:___________________________________________________
Date of birth: ___________________________________________________________
Address/Telephone:
_______________________________________________________________________
Relationship to the passenger
________________________________________________
Email Address: ______________
Financially Dependent on passenger - Yes/ No
5. First name, family name:___________________________________________________
Date of birth: ___________________________________________________________
Address/Telephone:
_______________________________________________________________________
Relationship to the passenger:
________________________________________________
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Email Address: ______________
Financially Dependent on passenger - Yes/ No
Please indicate further members of the family and their details on the reverse side of this
page or on a separate page.
III. Additional information, if available, on the occupation and the income of the passenger
1. Was the passenger employed? yes no (please mark with a cross)
If yes, please indicate occupation:
_______________________________________________________________________
If yes, please indicate the name, address and telephone of the employer:
_______________________________________________________________________
_______________________________________________________________________
2. Was the passenger self-employed? yes no (please mark with a cross)
3. Any further information you wish to state in respect of the passenger’s employment?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Please note that appropriate documents or further information may be called for at a later
date.
V. Information about the person filling out this questionnaire
Please kindly indicate the following:
First name, family name:
_______________________________________________________________________
Date of birth:
_______________________________________________________________________
Address, telephone and email:
_______________________________________________________________________
Relationship to the passenger:
_______________________________________________________________________
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VI. Name of the member of the family authorized to receive the interim compensation on
behalf of all members of the family*:
First name, family name:___________________________________________________
Date of birth: ___________________________________________________________
Address/Telephone:
_______________________________________________________________________
Relationship to the passenger:
_______________________________________________________________________
Bank Account Details:
Account Name:
Account Number:
Type of Account:
Bank:
Branch:
IFSC Code:
Any other relevant details of the bank account:
Please provide self-attested copies of the following documents of the member of the family
authorized to receive the interim compensation:
(a) PAN Card
(b) Aadhar Card
(c) Passport
(d) Bank account statement / passbook evidencing the bank account details
__________________________________________________________________________
Place and date: Name and Signature:
Mobile No.:
*Interim compensation will be paid against a receipt and indemnity (the form of which will be
provided after scrutiny of this form) being executed by the member of the family authorized to
receive interim compensation. Air India’s representatives will contact you for any additional
information or clarifications it may need after receipt of the form.
**Kindly note that the interim compensation does not include the ex-gratia payment of Rs. 1 crore, which
was announced by the Tata group. The ex-gratia payment will be a voluntary payment and is not
intended to constitute recognition of any liability. The details in this form will also be used for the
purposes of the ex-gratia payment, and the families will be contacted by the Tata group soon after we
have received the details in the form.
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