Printed On : 14-OCT-2020Licence No:SLA -31896 Tel.No.:28332089,28986989 Claim No : OC-21-1901-1803-00000139Mobile No.:-9821215937 Valid Upto :08/04/2022 Preliminary Survey Report Registration No : MH06BW2106 DATTA M.KORE Claim Id : CABIN STRIPING 19095155 3500 0 0 Claim No :3500 OC-21-1901-1803-000001390 AUTOMOBILE SURVEYOR,LOSS ASSESSOR &VALUERS Customer Name :CABIN RAJAN VINODKUMAR DUBEY 25000Preliminary Survey Report0 0 Registration No : MH06BW2106250000 Survey Status : P Email: datta.kore08@gnail.com Report Date : CHASSIS 4500 0 0 Claim No : OC-21-1901-1803-0000013945000 SurveyorRegion: C-107,Beach Classic Apt., Kanti Park,Shimpoli-Gorai Road, Chikuwadi, Borivali (W),Mumbai-92 Printed On : 14-OCT-2020TANK ASSY 0 Approval(Annexure-1)15000 0 0 15000 0 BJAZ Address : FINAL SURVEY BILL Survey Date :15-JUN-20 ELWCTRICAL 2500 0 0 2500 0 Surveyor Address :Surveyor CommentsFRONT AXLE: BAJAJ ALLIANZ GENERAL INSURANCECO. LTD.15000 0 1500 BILL NO:513/20-210 INSURER Damages are concurrent with statement of accident on claim form.Parts Report Claimant Name :Claim Id :19095155 BAGI AndheriRAJAN VINODKUMAR DUBEY57500 o 0 Phone No :57500 Date 0 21/10/2020 Date of Loss : Denting and Repairs291, Xtrium, 2nd Floor, Next To Holy Family Ghurch, Andheri-Kuria Road, Chakala, Andheri (E),QTYRetailTotalNetNetDeprNet As- Benefit 28-MAY-20 Price Tax Mobile No: Amt 9999999999 Flag Claim No : CHASSIS Mumbai-400099. 8500 Amount0 0 Amt 8500 0 sessed OC-21-1901-1803-00000139 1800 Document Checklist Survey Date : 15-JUN-20 Amt FRONT AXLE State : Maharashtra - 27 GSTIN No. : 27AABCB5730G1ZX 0 0 1800 0 Metal Description Enclosed(Yes/No)10300 0 0 Policy No :Description10300 OG-20-1908-1803-00001101Enclosed(Yes/No) INSURED : RAJAN VINODKUMAR DUBEY 0 Risk Start Date :COWLPainting 30-OCT-19 1 90000 90000 0 Risk End90000 9000 29-OCT-2081000 POLICY NO.CABINRegistration CertOG-20-1908-1803-000011011 65000 65000 o|Repairer EstimateDate :65000 6500 58500 PAINTING 15000 0 0 6562.5 8437.5 IMT 23 CLAIM NO.BRAKE PADEL VALVE OC-21-1901-1803-00000139Data1As Per Evidence5787 5787 0 5787 578.7 5208.3 Salvage Photo 15000 0 Satisfaction Voucher06562.5 8437.5 VEHICLE NO.CABIN BKTTotal Labour Amount:MH 06 BW 2106Make4 ASHOK LEYLAND40082800 1600 0 o| 0 1600 74362.5 160 8437.51440 SURVEYED AT : NON TIEUP REPAIRER on Dt.:HORNPhotographs1 400 400 o TL Report 400 40 360 Model 3118 IL STEERING GEAR BOXDriving License 1 23000 23000 0 TP loss Report23000 2300 20700 Details Year of Manf 2018 Amount COOLING ASSYDamage Part DetailsTotal Assessed Amount Parts :1 25000 25000 o 25000 2500202101 22500 Professional FeesRegistration NoTotal Assessed Amount Labour :SAC Code No.997162MH06BW21062107870 210787 21078.774363 Rs. :189708.3 5,000.00 PlasticPhotograph (@Rs. 10.00 x 0 Copy)Date Of RegSalvage Amount(On Parts) @ROREIS13-OCT-2018 9500 Rs. : 0.00 ACCELARATORE PADELConveyance ()Chassis NoTowing Charges1 1840 1840 0 1840 0920 Rs. :920 MB1KACHD9JAXJ6642 300.00 STEERING COVER Compulsary Excess 1 3180 3180 0 3180 15001590 1590 Engine NoVoluntary ExcessM 0000000000JYEZ429217 :0Total Rs. : 5,300.00 COVER 1 350 350 o 350 175 175 SEAT BELTCGST 9% On Rs. 5,000.00Auth.BAGIC SignatureAddl/Imposed Excess:Color17001700 1700 :0850 Rs. :850 1 0 450.00 HOOD Endt in RCTheft Excess 5500 5500 5500 :2750 2750 SGST 9% On Rs. 5,000.00depreciation Amount 1 o 44609 Rs. : 450.00 Speedometer ReadingFRONT BUMPERNett Assessed Amount (Parts Labour)114500 4500 o 4500 2250 1125 IMT23 Rounded to Nearest Rupees: 265464 HEADLAMP ASSEMBLYDriver Name 2 600 1200 o 1200 Net Total600 Rs.300 6,200.00IMT23 FOG LAMPRupees : Six Thousand Two Hundred Only 2 300 600 o 600 300 150 IMT23 DL No GST No. : 27AAPPK5632B1ZSCLUSTER MITER COVERPlace of Issue1 1500 Surveyor Signatare1500 0 State : Maharashtra Code:271500Auth.BAGIC Signature750750 CLUSTER MITER 1 7565 7565 o 7565 3782.5 3782.5 PAN No. : AAPPK5632B Endt in DL YMB 26360 o 26360 13967.5 12392.5 Total Parts AmountDL Endt Date 238722 0 238722 35046.2 202100.8 STATE BANK OF INDIA DL Exp Date Codification of Accident DATTA MKORE OG-20-1908-1803-00001101 Description of Loss Labour Details a 96 10 NA Claim Id :19095155 S SURVEYOR Advance Receipt a Allowed Net Tax WCT Assessed Paint Remarks TA M Amt Depr D c Removing and Refitting * COWL 5500 0 0 5500 0 H 17 E H 0 0 GOVT. S * E BAI