Er Harish C Gupta MARUTI/VITARA/2018: PB70 D 3025

Ref No. : HG/NICL/-D-3025/09-19/F/00197 Date : 24-09-2019

SUMMARY ASSESSMENT SHEET

Insurers National Insurance Co. Ltd., SECTOR 26 CHANDIGARH

Insured HARBANS SINGH KADIAN
Policy No. 42010031181143090919 IDV F 699099.00
Period of Insurance 16-03-2019 to 15-03-2020 Claim No. 42010031191194766031
Registered Number PB70 D 3025 Date of registration 16-03-2018
Engine Number 11337 Chassis Number 58875
Make/Variant/Model MARUTI/VITARA/2018
ACCIDENT PARTICULARS :
Date of Accident 21/09/2019 04:30 PM
Place of Accident ZIRAKPUR
Police Action Police Action : Not reported as per claimform.
Workshop TRICITY AUTO, ZIRAKPUR
Spot Survey Rec. N.A.
DRIVER PARTICULARS :
Name of Driver HARBANS SINGH ( 61 Years)
Motor Driver License Number HR-0320080064483 SDM OFFICE PANCHKULA
Type of License LMV, MCWG
Valid Up to 14-01-2023
Whether checked original DL CHECKED VERIFIED

DETAILS OF ASSESSMENT :
Final Survey Done on 23-September-2019
Under Repair Photographs Taken on
Reinspection Done on
Salvage Destroyed Yes

DETAILS OF ASSESSMENT :
Total Labour Charges GST on F 1062.00 @ 18.00 = 191.16 1253.16
Towing Charges 0.00
Total Cost of Parts 4940.99
Depreciation (NIL DEPRECIATION) :

Less Policy Excess 1000.00

Less Voluntary Excess 0.00
Less Wreckage Value 0.00
Total Amount of the Bill (Rs.) 6195.00
Amount to be Borne by the Insured 1000.85
Net Amount Payable to Dealer 5,194.00

Date : Signature of Surveyor

For Office Use Only
Documents Received
ALL DOCUMENTS REQUIRED FOR SETTLEMENT OF CLAIMS ARE AVAILABLE IN THE FILE AND PRIMA-FACIE IN ORDER AS PER THE
ASSESSMENT AND DOCUMENTS SUBMITTED THE CLAIM IS RECOMMENDED FOR RS. AS FULL AND FINAL SETTLEMENT

ASST / SR ASST AO AM
APPROVED FOR RS AS RECOMMENDED

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