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/2020-21/1104 Reserve Charge No Date of Issue 19/03/2021 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-21-1301-1826-00002620 DATE OF LOSS : 17/12/2020 POLICY NUMBER : 0G-21-1303-1826-00001871 PERIOD OF INSURANCE : From 14/03/2-020 To 13-Mar-2021 ESTIMATED LOSS : 9000.00 VEHICLE NO : UP 53 DS 1653 INSURER : Bajaj Allianz General Insurance CO LTd INSURED : SAROJ PASWAN Sr. No. Description HSN/SAC Amounts [In Rs.} 1 Professional Suryey Fee 500.00 Conveyance Expenses From Gorakhpur to Campierganj and back, 2 996172 600.00 i.e., 2 *40 = 80 @ 7.50 Per Km by Car No UP 53 AA 0419 3 Photographs Expenses 50.00 s Total 1150.00 Total Invoice Amount in Words: Total Amount Before Tax 1150.00 Rs. One Thousand Five Hundred Thirthy Four Add : CGST @ 09% 103.5 Add : UGST @ 09% 103.5 Add : IGST 0.00 Tax Amount : GST 207 Bank Details Total Amount After Tax 1357.00 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---