PIYUSH MATHUR Tel.

01482-250839, 98291-86845
Surveyor & Loss Assessor 6-D-33, New Housing Board
Licence no. SLA-49290 Shastri Nagar, Bhilwara (Raj.)
Valid Up-to : 22.11.2019 email:piyushmathur08@gmail.com

Ref No. : PM/NICL/SW-5557/04-19/F/01889 Date : 17/04/2019

PRIVATE & CONFIDENTIAL
MOTOR FINAL SURVEY REPORT
This report is issued by me/us as a licensed Surveyor(s) without prejudice in respect of cause, nature and extent of
loss/damages and subject to the terms and conditions of the insurance policy.
INSURANCE PARTICULARS :
(a) Policy / Cover Note No. : 380402311810003460 IDV : F 31,200.00
(b) Period of Insurance : 29/09/2018 to 28/09/2019 Claim No. : N.A.
(c) Endorsement : --
(d) Insurers : National Insurance Co. Ltd.
Branch Office-Chittorgarh. Meera Hotel, Nimbahera Road, Chittorgarh.
(e) Insured : Sh. Krishna Kant Koli S/o Sh. Ratan Lal Koli (8769681179)
53-Madhuvan 1st, Senthi, Chittorgarh .
(f) H. P. A. :
(g) Appointed By : Branch Office-Chittorgarh.
VEHICLE PARTICULARS : Original Verified
(a) Registered Number : RJ-09-SW-5557
(b) Registered Owner : Sh. Krishna Kant Koli S/o Sh. Ratan Lal Koli
Owner Serial No. / Transfer Date : 1
(c) Date of Registration : 27/08/2015
(d) Chassis Number : MD626BG48F3H38711 ( Physically Checked )
(e) Engine Number : BG4GF1614093 ( Physically Checked )
(f) Make / Variant/ Model /Color TVS Motor Co. Ltd. / Jupiter / 2015 - Grey
(g) Type: of Body and Class of vehicle : Solo - Scooter
(h) Pre Accident Condition : Roadworthy
(k) Seating Capacity : 2 Nos.
(l) Cubic Capacity : 110 CC Fuel Used : Petrol
(m) Tax particulars : Life time Valid Upto 26/08/2030
DRIVER PARTICULARS : Original Verified
(a) Name of Driver : Sh. Krishna Kant Koli S/o Sh. Ratan Lal Koli
Age : 27 Years ( 14/05/1992 )
(b) Motor Driver License Number : RJ09 20170003274
Date of Issue : 02/02/2017 Valid upto (NTV) : 01/02/2037
Valid from : Valid upto (TV) :
(c) Issuing Authority : Chittorgarh.
(d) Type of License : M/c wgr, LMV Only.
(e) Badge Number : --
ACCIDENT & SURVEY PARTICULARS :
(a) Date & Time of Accident : 10/04/2019 11.00 AM
(b) Place of Accident : Senthi, Chittorgarh.
(c) Place of Survey : Jain Auto Corp., Chittorgarh.
(d) Date of Allotment of Survey : 16/04/2019
(e) Date & Time of Survey : 16/04/2019
(f) Date of Receipt of Spot Survey Report : N.A.

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PIYUSH MATHUR PM/NICL/SW-5557/04-19/F/01889 - RJ-09-SW-5557
CAUSE & NATURE OF ACCIDENT :

As stated by insured in the claim form & explained to the undersigned that on the way ### ,causing damage to the
vehicle.
POLICE ACTION : Not reported
DETAILS OF LOAD / PASSENGER : NA

THIRD PARTY LOSS/ INJURIES : Not Reported.

PARTICULARS OF LOSS/DAMAGES :
In response to an advice received from Sr. Branch Manager of National Insurance Co. Ltd., Branch
Office-Chittorgarh. dated 16/04/2019, the under signed proceeded to M/s Jain Auto Corp., Chittorgarh. , I
have taken the survey assessment loss in the said vehicle & taken photographs. Based on the facts my report
is as follow:

Insured submitted the estimate of M/s Jain Auto Corp., Chittorgarh. , Rs. 11423.98
NEW PARTS :
Assessed F
HSN Bill Estimated GS
S. No Parts Description Remark Glass/ 2nd
Code S. No F Metallic (25) Non Metallic T
Hand/ Repair

1 Fork Assy. Front Bent(R) 3730.47 --- --- --- 28.00

2 Housing head lamp front 87141090 Cracked 527.34 --- --- 527.34 28.00
3 Head Lamp Assy. Intact 597.46 --- --- --- 18.00
4 Panel Front Top 87141090 Cracked 1015.62 --- --- 1015.62 28.00
5 Panel Front Bottom 87141090 Cracked 882.81 --- --- 882.81 28.00
6 Panel Rear 87149100 Cracked 460.94 --- --- 460.94 28.00
7 Floor Board 87149100 Cut 339.84 --- --- 339.84 28.00
8 Side Trim Floor L 87141090 Cracked 339.84 --- --- 339.84 28.00
9 Side Trim Floor R NA 339.84 --- --- --- 28.00
8234.2 0.0 0.0 3566.4
Add : Applicable GST : 2245.82 0.00 0.00 998.59

Total : 10479.98 0.0 0.0 4565.0

Less: Depreciation : 0.00 0.00 2,282.49

Net Total F : 10480.0 0.0 0.0 2282.5

Grand Total F : 10480.0 2,282.49

LABOUR & REPAIRS :

S. No. SAC Labour Description Estimated F Assessed F
1 9987 Opening & Refitting Charges 800.00 400.00
2 9987 Fork Repairing Charges 0.00 700.00
800.00 1100.00
Sub Total Labour Charges : F
Add : GST on F 1,100.00 @ 18.00% : 144.00 198.00
Total Labour Charges : F 944.00 1298.00

SUMMARY OF ASSESSMENT :
PARTICULARS ORIGINAL ESTIMATE ASSESSED FOR

Total Labour Charges F 944.00 1,298.00

Total Cost of Parts (+) F 10,479.98 2,282.49
Total :F 11,423.98 3,580.00
Less : Excess :F --- 100.00
:F --- 0.00
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PIYUSH MATHUR PM/NICL/SW-5557/04-19/F/01889 - RJ-09-SW-5557
Total :F 3,480.00
Less : Salvage :F --- 0.00
Net Assessed Amount F 3,480.00

GST Summary Tax Wise

Sr. No. Tax Percentage Actual Allowed C GST S GST I GST Total

1 18.00 0.00 0.00 0.00 0.00 0.00

2 28.00 1,783.20 249.65 249.65 0.00 2,282.49

Grand Total 1,783.20 249.65 249.65 0.00 2,282.49

Sr. No. Service Acc. Code GST % Actual Allowed C GST S GST I GST Total

1 9987 18.00 1,100.00 99.00 99.00 0.00 1,298.00

Grand Total 1,100.00 99.00 99.00 0.00 1,298.00

Based on details provided above, the liability under the subject policy of insurance works out to F 3,480.00
(RUPEES THREE THOUSAND FOUR HUNDRED EIGHTY ONLY) The assessment of loss, as detailed above, is subject to
the terms and conditions of the policy of insurance.
Remarks :
1. Cause and nature of accident appears to be genuine and believable.
2. All documents have been verified from originals and found in order.
3 Rates allowed for replacement of parts are as per authorized dealer price list and repair allowed as per
prevailing market rates.
4. Vehicle was Re-inspected after repair and found that all the parts repaired / replaced which allowed.

Thanking you and assuring you of my best services at all times,

Issued Without Prejudice

PIYUSH MATHUR
SURVEYOR & LOSS ASSESSOR

Enclosures : Survey Fee Bills, Claim Form, Estimate of repairs, Photographs [<PT> Nos.] .

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