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/2020-21/540 Reserve Charge No Date of Issue 21/12/2020 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 : oc-21-1301-1843-00000461 DATE OF LOSS : 07/12/2020 POLICY NUMBER : 0G-19-1303-1843-00003817 PERIOD OF INSURANCE : From 13-Jan-2020 To 12-Nov-2025 ESTIMATED LOSS : 7069.00 VEHICLE NO : UP 57 AP 5731 u INSURER : Bajaj Allianz General Insurance CO LTd INSURED : AMIBA KHATOON E Sr. No. Description HSN/SAC Amounts [In Rs.} 1 Professional Suryey Fee 750.00 Conveyance Expenses From Gorakhpur to Tukpatti Kushinagar and back, 2 996172 1050.00 i.e., 2 *70= 140 @ 7.50 Per Km by Car No UP 53 AA 0419S 3 Photographs Expenses 50.00 Total 1850.00 Total Invoice Amount in Words: Total Amount Before Tax 1850.00 Rs. One Thousand Five Hundred Thirthy Four Add : CGST @ 09% 166.5 Add : UGST @ 09% 166.5 Add : IGST 0.00 Tax Amount : GST 333 Bank Details Total Amount After Tax 2183.00 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---