VIJAY KR. BHATIA Email vkbhatia81@gmail.

com

SURVEYOR & LOSS ASSESSOR 58, DWARKA PURI

APPROVED BY GOVT. OF INDIA SIRSA - 125 055
SURVEYOR LICENCE NO. 37795 MOBILE No. 98962-70645
VALID UPTO 16.09.2017

Ref No. UIIC 103/2017 Dated 23.02.2017

WITHOUT PREJUDICE
PRIVATE AND CONFIDENTIAL
MOTOR SURVEY FINAL
This report is issued by me as Licenced Surveyor without prejudice, in respect of cause, nature & extent of
loss/damage and subject to the terms & conditions of Insurance Policy.

Policy/Covernote No. : 111985 3116P107372326

End. No. : -
Effective from : 05-09-2016 to 04-09-2017
IDV : 20000/-
United India Insurance Co. Ltd.,
INSURERS :
M.O., ELLENABAD.
INSURED : Sh. Kamaljeet Singh S/o Sh. Kabir Singh
(Address) : R/o VPO mallekan, Sirsa
FINANCIER , if any :
VEHICLE PARTICULARS RC CHECKED & FOUND OK
a) Registered No. : HR 24P 5376
b) Registered Owner : Insured himself
c) Date of Registration : 25/11/2011
d) Chasis No. : 13019 ( Physically Verified )
d) Engine No. : 25647 ( Physically Verified )
f) Make/Model : Hero Honda Motors Ltd., /2011
g) Type of Body : SOLO
h) Class of Vehicle : CD DLX CCR M-Cycle
I) Pre-accident condition : Good
j) Registered Laden Weight : -
k) Unladen Weight : -
l) Fitness Certificate No. : -
Valid Upto : -
m) Permit No. : -
Valid Upto : -
n) Type of permit : -
o) Passenger/Load Carrying Capacity : -
p) Token Tax paid upto : One Time Tax Paid
q) Route/area of operation : -
DRIVER PARTICULARS MDL CHECKED & FOUND OK
a) Name & address of Driver : Sh. Daya Ram S/o Sh. Beg Raj
: R/o Vill. Malwani, Tehsil nohar, Distt. Hanumangarh
b) M.D.L. No. : RJ-31A/DLC/11/17739
c) Date of Issue : 1/3/2011
d) Valid Upto : 9/1/2030
e) Issuing Authority : L.A. NOHAR
Type of Licence : M.C.with Gear, Light Motor Vehicle only
VIJAY KR. BHATIA Email vkbhatia81@gmail.com

DETAILS OF ACCIDENT
a) Date & time of accident : 16-02-2017 at about 06:30 p.m.
b) Place of accident : Near Vill Phephana, Sirsa
c) Date of allotment of Survey : 1/2/2017
0 Date & time of survey : 17/02/2017
e) Date of receipt of spot survey report : 17/02/2017
DETAIL OF LOAD CHALLAN : N.A.

IF MATTER R EPORTED TO THE POLICE : Not Reported

THIRD PARTY LOSS/INJURIES (if any) : Not Reported

VERIFICATION
a) Registration Certificate : Yes Found O.K
b) Driving Licence : Yes Found O.K
c) Route Permit : -
VEHICLE WILL BE SHIFTED TO/REPAIRED
: At M/s Devi Motors, Mallekan.
AT

NAME & ADDRESS OF INSURED REP at the

: Insured himself
time of Final/Spot survey

CAUSE OF NATURE OF ACCIDENT

As stated & also reported in the enclosed claim form, the subject vehicle was on its way, near the site of
accident, A TP Auto rick shaw hit with frt side of insured M-cycle after which m-cycle in question fell down
and sustained damages.

Note :- Damages sustained to the vehicle were fresh in nature & attributed to cause & history of
accident as narrated by insured.
DETAILS OF LOSS/DAMAGE

Under valuable advices received from Insurer office on dt. 17-02-2017 in connection with the job relating
to survey of said vehicle I, the undersigned , visited the repairer workshop of M/s Devi Motors,
mallekan, where said Vehicle had been parked after accident. I collected all the relating particulars &
physically verfied its Chassis No. & Engine No.I found the vehicle damages affacted at its Front side
mainly. Due to impact I found its -- Front Visor cut, Head Light broken, Head Light stey bent, Handle Bar
bent, Leg Guard bent, Brake Lever broken, Side Mirror broken, Indicator cut, Comp Meter cut, Shocker
Pipe & Handle Tee

Loss position was discussed in details with insured & repairer. Estimates submitted by insured & received
through your good office were item wise checked & discussed in details I arranged photographs of
accidental vehicle for claim records. Outer parts were dismentalled to ascertain interior damages . After a
quite lengthy repeated pursuations the loss was assessed keeping in view the cause & nature of
loss.Details of loss assessed as per details on attached sheet :-
VIJAY KR. BHATIA Email vkbhatia81@gmail.com

SURVEYOR & LOSS ASSESSOR 58, DWARKA PURI

APPROVED BY GOVT. OF INDIA SIRSA - 125 055
SURVEYOR LICENCE NO. 37795 MOBILE No. 98962-70645
VALID UPTO 16.09.2017

1 Insured Name : Sh. Kamaljeet Singh S/o Sh. Kabir Singh

2 Date of Loss : 16-02-2017 at about 06:30 p.m.

3 Policy No. : 111985 3116P107372326

 Email vkbhatia81@gmail.com
V.K.BHATIA
New Parts Assessed
Sl. No. Description Estimated Metal Plastic Glass
1 Front Visor 880.00 870
2 Head Light 515.00 415
3 Leg Guard 520.00 470.00
4 Handle Pipe 380.00 340.00
5 Brake Lever 75.00 65.00
6 Side Mirror 105.00 80
7 Head Light Stey 165.00 135.00
8 Handle Tee 680.00 Repairable
9 Shocker Pipe 1,550.00 Repairable
10 Handle Lock 450.00 NA
11 Front Mudguard 780.00 NA
12 Indicator 165.00 140
13 Comp Meter 1,080.00 990
TOTAL 7345.00 1010.00 2495.00 0.00
Tax Paid 0.00 0.00 0.00 0.00
GROSS TOTAL 7345.00 1010.00 2495.00 0.00
Less Dep. @ 40% on Metal & 50% on Rubber 404.00 1247.50 0.00
Net New Parts Assessed 7345.00 606.00 1247.50 0.00
TOTAL OF NET NEW PARTS 1853.50

LABOUR
Sl. No. PARTICULARS ESTIMATED ASSESSED
1 Workshop Labour 800.00 250.00
2 Both Shocker Pipes & Handle tee alignment New Dem 350.00
Total 800.00 600.00
Add 0% Service Tax 0.00 0.00
Total Assessed Labour 800.00 600.00
SUMMARY OF ASSESSMENT ESTIMATED ASSESSED
1 COST OF NEW PARTS 7345.00 1853.50
2 COST OF NEW REPAIR 800.00 600.00
3 TOTAL LOSS ASSESSED 8145.00 2453.50
4 Less Policy Clause 100.00
5 Less Salvage Value 50.50
6 Net Loss Assessed 2303.00
REISNPECTION
Under advices I again reisnpected the vehicle after repairs I found all the recommended parts
newly replaced/repairings done properly.
REMARKS
1 Rates of New Parts assessed are as per Authorised Dealer Price List
2 Damages assessed are attributed to cause & nature of accident.
3 Engine & chasis numbers are physically verified
ENCL VIJAY KR.BHATIA
1 Estimate, Claim Farm SURVEYOR & LOSS ASSESSOR
2 Photocopy of RC, Ins policy , Photographs & Fee Bill
 VIJAY KR.BHATIA
Surveyor & Loss Assessor

SURVEYOR LICENCE NO. 37795 Office

Valid Up To 16-9-2017 58 Dawarka Puri , Sirsa

Ref No. UIIC 103/2017 Dated 23.02.2017

Policy No. 111985 3116P107372326 Vehicle No. HR 24P 5376
Ins Co. name UIIC, ELLENABD
PAN NO . AARPB5550D
Bank A/C No. 3326000100194942

Sh. Kamaljeet Singh S/o Sh. Kabir Singh

S No. Description Amount

1 Profesional Fee 750.00

2 Local Conveyance

3 Photographs Charges 12 nos @ Rs 10/- each 120.00

4 Halting Charges 300.00

###
5 Travelling Expenses by Car From Sirsa To Mallekan 525.00
For Final & Reinspection inclusive of travelling expenses
50 Kmt. @ Rs 10.50 Per Km

6 Reinspection Fee Nil

TOTAL 1695.00

###
VIJAY K.BHATIA

My Bank A/c Detalis for Fee RTGS Purpose

PAN NO . AARPB5550D
Bank A/C No. 3326000100194942
Bank Name P.N.B Circular Road Sirsa
RTGS/NEFT IFSC Code PUNB 0194700
MICR NO. 125024003
 .

90 8.7

144 7
 1747 80 78

1524 81 73

75 85

85 76 81

167 88 83

231 82

323 400

291 482

1802
142
133
186
1077
4474
3948
117
140
117
170
189
228
151
229
324
130
277
1024
990
639
7866

TOTAL TDS 28721