FINAL SURVEY REPORT Report Date :Thursday 17-September-2020 Claim Number OC-21-1103-1802-00001524 Policy Number OG-20-1101-1802-00017735 Policy Inception Date 04-OCT-2019 Policy Expiry Date 03-OCT-2020 Customer Name JAVED ANSARI Vehicle Reg.Number UP37J5805 Telephone No Mobile Number 9953805701 Customer Address Hno 829 gadhi pi|khuwaHapur ghaziabadGHAZIABADUTTAR PRADESH245101 Repairer Name NON TIEUP REPAIRER Registration No UP37J5805 Vehicle Reg.Date 17-JUL-2018 Make HERO MOTOCORP Model SUPER SPLENDOR Chassis No 00000000000E63445 Engine Number 000000000000E13871 Vehicle Register As Two Wheeier Cubic Capacity Manufacture Year 2018 Color Metallic Hypothecation HERO FINCORP LTD RTO Endorsement LMVNT Odometer Reading 2 Vehicle Parked No Relation With PHI Self Driver Name JAVED ANSARI Driving License No UP14 20120012671 Date of issue 13-MAR-2012 Date of Expiry 12-MAR-2032 MDL Issuing Authority GHAZIABAD DL Endorsement LMVNT Driving License Type Permanent Date of Loss 08-SEP-2020 Intimation Date Claim Registration Date 12-SEP-2020 Date of Survey Allot- 14-SEP-2020 ment Date of Survey 17-SEP-2020 Survey Report Status FSR Generated Description of Loss NIL GAY A GAI Surveyor Comments Damages are concurrent with statement of accident on claim form. DWIV t Suryveyai inatur Auth. BAGIC Signature * SUR Report Printed On : 17-09-2020 03:07:48 ---PAGE END--- Claim No : OC-21-1103-1802-00001524 Registration No :UP37J5805 Printed On : 17-SEP-2020Approval(Annexure-1) Parts Report Claim Id20327126 QTY Retail Total Net Net Depr Net As- Benefit Price Amount Tax Amt Amt sessed Flag Amt Metal PIPE STRG HANDLE 1 257 257 71.96 328.96 49.34 279.62 S3 257 71.96 328.96 49.34 279.62 Plastic HEADLAMP ASSEMBLY 1 466 466 83.88 549.88 274.94 274.94 S3 WIND SCREEN ASSY 1 234 234 65.52 299.52 149.76 149.76 S3 SET FR COWL 1 949 949 265.72 1214.72 607.36 607.36 S3 1649 415.12 2064.12 1032.06 1032.06 Total Parts Amount 1906 487.08 2393.08 1081.4 1311.68 Labour Details Claim Id : 20327126 Allowed Net Tax WCT Assessed Paint Remarks Amt Depr Removing and Refitting ALL PARTSOP/RF 338 60.84 0 398.84 0 S3 338 60.84 0 398.84 0 Denting and Repairs FR SHOCKER ROD REPAIR 250 45 0 295 0 S3 ALLPARTSOP/RF 1 .18 0 1.18 0 S3 251 45.18 0 296.18 0 Total Labour Amount 589 106.02 0 695.02 0 Total Assessed Amount Parts : 1312 Total Assessed Amount Labour : 695 Salvage Amount(On Parts) @ :0 Towing Charges :0 ---PAGE END--- Voluntary Excess :0 Addl/Imposed Excess : :0 Theft Excess :0 depreciation Amount 1081 S3 - Depreciation : 1081 Nett Assessed Amount (Parts + Labour) : :2988 W Surveyor Signaturer Auth. BAGIC Signature REPORT ISSUED WITHOUT PREJUDICE SUBJECTED TO POLICY TERMS AND CONDITIONS ---PAGE END--- GST No.09ACVPD6053B1ZM State Uttar Pradesh TAX INVOICE PAN.ACVPD6053B Code 09 SANJAY DWIVEDI Surveyor & Loss Assesor License No. : 36742 Valid Upto : 29th April 2023 B-52, Ganga Nagar, Mawana Road, Meerut (UP) Ph. : 0121-4033709, 9837109331 Email : dwivedi_sanjay11@yahoo.co.in Invoice No. 6107/2020-2021 Date 17-09-2020 Policy No. OG-20-1101-1802-00017735 Claim No. OC-21-1103-1802-00001524 BAJAJ ALLIANZ GENERAL INS. CO.LTD Insured JAVED ANSARI Block No 04, 7 Th Floor,DLF Tower 15 Shivaji Marg New Delhi Vehicle No. UP 37 J5805 Make SUPER SPLENDOR Date of Survey 16-09-2020 Place of Supply Uttar Pradesh GST No.:07AABCB5730G1ZZ Estimated Amt.Rs. 5000.00 State DelhiCode:07 Assessed Amt.Rs. 2988.00 HSN/SAC AmoutSGST SGSTCGST CGST IGST IGST Total S.No.Particulars of Services Code Rate Amount Rate| Amount Rate Amount Amount 1. Final Survey Fee 997162 400.00 0.00 0.00 0.00 0.00 18.00 72.00 472.00 2. Final Survey Conveyance 997162 750.00 0.00 0.00 0.00 0.00 18.00 135.00 885.00 Total 1150.00 0.00 0.00 207.00 1357.00 Amount in Words : Rupees One Thousand Three Hundred Fifty Seven Only OUT STN CONVAINCE FROM MEERUT TO PILKHUWA & BACK 100KM @ RS 7.5/KM =750.00 AY Bank A/C Detail : 1 1 8 S A/c No. 4038000100039677 [PNB, Ganga Nagar, Mawana Road, Meerut] IFSC : PUNB0403800 RW K A/c No. 50100051796221 [HDFC bank Ltd.,381 W.K.Road,Meerut] IFSC :HDFC0000285 SANJAYDWIVEDI ---PAGE END---