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 21.02.2017

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. : 111987 3115P113814060

End. No. : -
Effective from : 14-02-2016 to 13-02-2017
IDV : 39500/-
United India Insurance Co. Ltd.,
INSURERS :
D.O., SIRSA
INSURED : Sh. Gobind S/o Sh. Udha Ram
(Address) : R/o Gali No. 4, Shastri Colony, Sirsa
FINANCIER , if any :
VEHICLE PARTICULARS RC CHECKED & FOUND OK
a) Registered No. : HR 24U 5201
b) Registered Owner : Insured himself
c) Date of Registration : 25/02/2015
d) Chasis No. : 8011340 ( Physically Verified )
d) Engine No. : 82011110 ( Physically Verified )
f) Make/Model : Honda Motor India Pvt Ltd. /2015
g) Type of Body : SOLO
h) Class of Vehicle : Activa 3G Scooter
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. Gobind Lal S/o Sh. Uda Ram
: R/o 16/595, Shastri Colony, Opp. RSD Colony, Sirsa
b) M.D.L. No. : HR-24 19880027280
c) Date of Issue : 4/1/1988
d) Valid Upto : 2/8/2018
e) Issuing Authority : LAMV SIRSA
Type of Licence : LMV, Tractor, MCWG only
VIJAY KR. BHATIA Email vkbhatia81@gmail.com

DETAILS OF ACCIDENT
a) Date & time of accident : 02-02-2017 at about 04:00 p.m.
b) Place of accident : Barnala road, Sirsa.
c) Date of allotment of Survey : 3/2/2017
0 Date & time of survey : 3/2/2017
e) Date of receipt of spot survey report : -
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 Telmos Automobiles, Pvt. Ltd., Sirsa.
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 M-cycle was on its way, near the site of
accident, at the crossing chowk a TP Tata Ace Vehicle 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. 03-02-2017 in connection with the job relating
to survey of said vehicle I, the undersigned , visited the repairer workshop of M/s Telmos Automobiles,
Pvt. Ltd., Sirsa. 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 Lh side
mainly. Due to impact I found its --

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. Gobind S/o Sh. Udha Ram

2 Date of Loss : 02-02-2017 at about 04:00 p.m.

3 Policy No. : 111987 3115P113814060

 Email vkbhatia81@gmail.com
V.K.BHATIA
New Parts Assessed
Sl. No. Description Estimated Metal Plastic Glass
1 Lh Click 1,454.00 1,412.93
2 Lh Floor 862.00 NA
3 Lh Cover 1,095.00 Repairable
4 Foot Rest 765.00 725.00
5 Handle Bar 519.00 NA
TOTAL 4695.00 2137.93 0.00 0.00
Vat 13.125% 616.22 280.60 0.00 0.00
GROSS TOTAL 5311.22 2418.53 0.00 0.00
Nil Dep Policy 0.00 0.00 0.00
Net New Parts Assessed 5311.22 2418.53 0.00 0.00
TOTAL OF NET NEW PARTS 2418.53

LABOUR
Sl. No. PARTICULARS ESTIMATED ASSESSED
1 Workshop Labour 600.00 252.00
2 Lh Click painting 1200.00 999.60
3 Lh Floor painting 700.00 NA
4 Lh Cover painting 800.00 699.60
5 Fork Aligment Repair 350.00 NA
Total 3300.00 1951.20
Add 15% Service Tax 495.00 292.68
Total Assessed Labour 3795.00 2243.88
SUMMARY OF ASSESSMENT ESTIMATED ASSESSED
1 COST OF NEW PARTS 5311.22 2418.53
2 COST OF NEW REPAIR 3795.00 2243.88
3 TOTAL LOSS ASSESSED 9106.22 4662.41
4 Less Policy Clause 100.00
5 Less Salvage Value 120.93
6 Net Loss Assessed 4441.49
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 21.02.2017

Policy No. 111900 3115P113814060 Vehicle No. HR 24U 5201
Ins Co. name UIIC, SIRSA
PAN NO . AARPB5550D
Bank A/C No. 3326000100194942

Sh. Gobind S/o Sh. Udha Ram

S No. Description Amount

1 Profesional Fee 750.00

2 Local Conveyance 300.00

3 Photographs Charges 09 nos @ Rs 10/- each 90.00

4 Halting Charges NIL

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

6 Reinspection Fee Nil

TOTAL 1140.00

###
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