GSTIN 09ADCPC7373H1ZJ Mob - 9415210795 RAJESH CHANDRA GOVT. APPROVED SURVEYOR & LOSS ASSESSOR Licence No. SLA 15141 Valid Up to 23-Mar-2020 SURVEY FEE BILL Document No. RC/BAGIC/2020-21/323 Reserve Charge No Date of Issue 02/11/2020 Place of Supply Gorakhpur Details of Receiver | Billed to: Details of Consignee | Shipped to: Name Bajaj Allianz General Insurance Co. Ltd. Name Bajaj Allianz General Insurance Co. Ltd. Address Bank Road, Gorakhpur Address Bank Road, Gorakhpur GSTIN 09AABCB5730G1ZV GSTIN 09AABCB5730G1ZV State Uttar Pradesh State Code 09 State Uttar Pradesh State Code 09 CLAIM NUMBER : 0C-21-1301-1843-00000263 DATE OF LOSS : 29/10/2020 POLICY NUMBER : 0G-20-4742-1843-00000979 PERIOD OF INSURANCE : From 5-Jan-2020 To 4-Jan-2020 ESTIMATED LOSS : 19000.00 VEHICLE NO : UP 52 BF 3239 INSURER : Bajaj Allianz General Insurance CO LTd INSURED : PRIHTVI JAIWAL Sr. No. Description HSN/SAC Amounts [In Rs.} 1 Professional Suryey Fee 750.00 Conveyance Expenses From Gorakhpur to DEORIA and back, i.e., 2 2 996172 750.00 *50 = 100 @ 7.50 Per Km by Car No UP 53 AA 0419 3 Photographs Expenses 50.00 s Total 1550.00 Total Invoice Amount in Words: Total Amount Before Tax 1550.00 Rs. One Thousand Five Hundred Thirthy Four Add : CGST @ 09% 139.5 Add : UGST @ 09% 139.5 Add : IGST 0.00 Tax Amount : GST 279 Bank Details Total Amount After Tax 1829.00 Bank Name : UNITED BANK OF INDIA A/c No. : 0497010064912 MICR No : 273027002 IFS Code : UTBI0GRR519 Terms and Conditions : RAJESH CHANDRA Surveyor & Loss Assessor Office Cum Residance ---PAGE END---