Lic.no.: 26815/Exp. 28.01.2023         B.K. Gupta       Surveyor, Loss Assessor & Valuer
                                           2-Ka-15,Dadabari, Kota-9
Phone :94141-88998                                          E-mail : bkgsurvey@yahoo.co.in
GSTI No.: 08ABYPG9645A1ZA                                             PAN No.: ABYPG 9645 A
Bajaj Allianz Generali Insurance Co. Ltd. (Raj.) GSTI No. : 08AABCB5730G1ZX
Bill noBaj-66                                                                            Date : 13.10.2020
Issued to.
M/s Bajaj Allianz General Insurance Co. Ltd.
A/c:Mr.Seva Lal
Reg.: Final Survey of Vehicle no. RJ-17-EP-0030
Policy/C.note no./Period : OG-21-3284-1803-00000249 / 24.09.2020 to 23.09.2021
Claim no.: OC-21-1401-1803-00000303                        S/Allott. Date : 29.09.2020
Date of Loss : 28.09.2020                                             S/Rep.no.: Bajaj/MT/20-21/66
                                                                                                    Rs.        750.00
2.Photographs CD                                                                         Rs.            0.00
3.Local Conveyence                                                                     Rs.           0.00
4.Out station Expanses : Kota to J.Patan (180 Kms.To & fro)                  Rs.         765.00
    @ 8.5/Km. [Charged 1/2 alongwith one another claim at
   same] (1530/2=765)
5.Haulting Allownce:117/2=58/-                                                      Rs.          58.00
6.Other Expanses                                                                          Rs.
                                                                                                                 1573.00
                                                                      CGST    9.00%        Rs.         141.57
                                                                      SGST    9.00%        Rs.         141.57
                                                                              Total              Rs.       1856.14
(Rupees One Thousand Eight Hundred Fifty Six Paisa Fourteen Only)

---PAGE END---