SURVEYOR NAME

B.Tech., M.B.A. Insurance Surveyor & Loss Assessor

Licence No: 70707, Validity: 14/09/2019 GST No.: AA0907173123536
Membership (IIISLA) No.: L/N/5857

MOTOR (FINAL) SURVEY REPORT

Private & Confidential

Ref. No.: VN/2017/F/19 Date: 30/04/2017

This report is issued without prejudice, in respect of cause, nature and extent of loss/damage and
subject to the terms and conditions of the Insurance Policy and Insurer admitting liability.

Subject : Claim for Veh. Regn. No. KA 02C XXXX, Accident Date : 01/12/2016
Insured : MR.XXXXXANA.S.P
Policy No. : 672401311501000XXXXX
Appt. Officer : BRANCH MANAGER

Insurance Particulars

Insurer : NEW INDIA ASSURANCE CO LTD

NEW INDIA ASSURANCE CO LTD,CHANDAN
COMPLEX,HARSHAMAHAL ROAD,HASSAN,
KARNATAKA
Appointed By : NEW INDIA ASSURANCE CO LTD,
CHANDAN COMPLEX, HARSHAMAHAL ROAD,
HASSAN-573201
Insured : MR.XXXXXANA.S.P
S/O XXXXXXLLY VILLEGE,DODDAPURA
POST,KASBHA HOBLI,HASSAN TALUKHASSAN
DISTRICT M-99728XXXXX
Policy No./Cover Note No. : 672401311501000XXXXX
Period of Policy : 13/06/2016 To 16/01/2017
IDV : Rs. 400000.00
HPA With : BANK OF BORODA

Vehicle Particulars RC: VERIFIED

Registration No. : KA 02C XXXX

Registered Owner : MR.XXXXXANA.S.P
Date of Purchase : 24/08/2005
Date of Registration : 24/08/2005
Chassis No. : 373344HUZ7XXXXX Physically Verified : Yes
Engine No. : 697TC55FUZ1XXXXX Physically Verified : Yes
Engine Capacity : 1000 CC
Vehicle Make : TATA
Vehicle Model :
Vehicle Variant : TATA/LPT 1613
Type of Body : OPEN B
Pre- Accident Condition : GOOD
Colour of Vehicle : NA3
Tax paid upto : 31/07/2016
Class of Vehicle : HGV
Seating Capacity : 3
Odometer Reading : 34545 Kms
Fuel used as per RC : Diesel
Fitness Certificate No. : KA13/XXXX/2016-17 VERIFIED
Valid upto : 23/06/2016
Permit No. : NP/KA/13/06XXXX/3117 NOT APPLICABLE
A-X, XXXXXX Nagar, Behind Vishwakarma Temple, Hirapur Road, Mohaba Bazar, Raipur (C.G.)
surveyorname@rediffmail.com, surveyorname@gmail.com :: 966907XXXX, 930006XXXX
VN/2017/F/19 KA 02C XXXX Page 2 of 6

Valid upto : 21/06/2020

Authorization No. : NP/KA/13/062015/3117
Valid upto : 21/06/2020
Permit Type : KARANATAKA STATE PERMIT
Route / Area of Operation : THROUGH OUT KARNATAKA
Whether valid for the state in which : Yes
accident took place?
Load Challan No. : Not available N/A
Registered Laden Weight : 16200
Unladen Weight : 6150
If overloaded, whether the overloading is
: No, indicated it is empty at the time of accident. So
the cause of accident?
it seems that overloading is not the reason of
accident.

Driver Particulars DL: VERIFIED

Name of the Driver : MR.XXXXANA.S.P

Driver DOB : 01/06/1967
Driver Address : CHAKANAHALLI,HASSAN DIST 573201
Relation with the insured : OWNER
Driving License Number : KA13199300XXXXX
Valid from : 27/09/1993 Upto 25/06/2019
Issuing Authority : HASSAN
Type of License : PERMANENT
Type of Vehicle Allowed To Drive : HGV
Endorsement Details : LMV,TRANS,PSV BUS
Badge No. : XXXX/BUS
Additional Comments : It is observed that insured is driver at the time of
accident

Accident Particulars

Date and Time of Accident : 01/12/2016 08:30 PM

Place of Accident : TAMIL NADU STATE
Place of Survey : XXXXX INDUSTRIES,B.N.ROAD,HASSAN
Date of request for Survey : 06/12/2016
Date and Time of Survey : 06/12/2016 10:30 AM next of the intimation
survey done.
Date of Under Repair visits : 06/12/2016 10/01/2017 08/02/2017
Insured's rep. attending survey : INSURED ATTENDED
Was veh. left unattended after accn : No

Particulars of Police Report

Has accident been report to Police : No
Has Panchnama been carried out : No

Particulars of Third Party Injury/Loss : No

Injury to Driver/Occupant (If any) : No

Spot Survey
Spot Survey By : N.A.
Spot Survey report received on : N.A.

Cause and Nature of Accident

As reported by the insured in his claim form on the day of occurence insured vehicle was on its way to
Hassan, at the spot of accident satthi ghat T.N, A TP vehicle came from opposit directionand approchd
VN/2017/F/19 KA 02C XXXX Page 3 of 6

the insured vehicle rashly and neglectly almost head on,In this driver cum owner also insured Mr.
Narayana.S.P. of Insured vehicle, applied the sudden brake to avoid the accident,despite his best
efforts, proved futile and vehicle skidded and hit to stone embackments. Hence cused the damages to
insured vehicle cabin and front portion

Actions of Survey

In accordance to your instructions,I the undersigned has visited the workshop of N.S.Sagar Industries,
B.M.Road, Hassan, and conducted the survey and details of which are as follows:

Particulars of Loss/Damages
Cabin and front end structure: front grill and front RH cowl panel-twisted and pressed badly;RH side
cabin sheets were damaged;it was replacedBattery;damaged; Chassis bent;fr cross
memebr-pressed;Front glass-broken and side cabin glass-broken;glass rubber beading-damaged;cabin
inside ply wood and sum mica damaged;cabin wirings-damaged; Cabin rebuild bolts and
nuts-damaged;key borad planks-damaged;radiator and inter cooler-damaged.

Original Estimate
Estimate no. est/nssi/0867/16-17 dated 10/12/2016 for Rs.433,821.00 was submitted by
XXXXX INDUSTRIES,B.N.ROAD,HASSAN.

Observation

On through and minute observation of vehicle found that, The cause of accident stated is co-relates
with damages.The damaged parts allowed are confirmatory with causeof accident. appears to fresh
damages and No previous damages found.

(ssued withour Prejudice)

SURVEYOR NAME

Insurance Surveyor & Loss Assessor

Enclosures:
1.Survey Fee Bill 2.Bill/Invoice 3.Claim Form 4.Copy of D.L. 5.Estimate Copy 6.Copy of Letter to
Insured 7.Copy of Policy/C. Note 8.Copy of Fitness 9.Copy of Permit 10.Photographs 11.Towing Charge
Slip 12.Report in Duplicate
 VN/2017/F/19 KA 02C XXXX Page 4 of 6

LOSS ASSESSMENT

In respect of Vehicle Registration No. KA 02C XXXX, Accident Date : 01/12/2016

(Annexure 'A' attached to Survey Report No. VN/2017/F/19)

ASSESSMENT OF LOSS (PARTS)

S. Description of Parts QE QA Est. Rate Estimated Assessed Parts Amount Remark

No. (Amt in `)
Metal Rub/Plast Glass

1 Turbo Inter Cooler 1 1 22000.00 22000.00 9700.00 - - Damaged

2 Radiator 1 1 16000.00 16000.00 12450.00 - - Damaged
3 Battery 1 1 12000.00 12000.00 - 7000.00 - Bent and
twisted badly
4 Fr Rh Shape And Grill 1 1 20000.00 20000.00 18000.00 - - Bent and
twisted badly
5 Fr Perch Cross Member 1 1 3000.00 3000.00 2980.00 - - Bent and
twisted badly
6 Bolts And Nuts(hard Ware) 1 1 4000.00 4000.00 3800.00 - - Damaged
7 Cabin Angles And M.s Sheets 1 1 36000.00 36000.00 8500.00 - - Bent
8 Cabin Tinkering Charges 1 1 0.00 - - - - Bent and
twisted badly
9 Main Axle Bent Removing 1 1 0.00 - - - - Bent
10 Chassis Bent Removing 1 1 0.00 - - - - Bent
11 Cabin Ply Wood 1 1 15000.00 15000.00 13300.00 - - Broken
12 Key Board 19 Mm Ply Wood 1 1 4500.00 4500.00 3849.00 - - Broken
13 Front Perch 1 1 2000.00 2000.00 1890.00 - - Bend
removing
14 Fr Jula 1 1 700.00 700.00 690.00 - - Bend
removing
15 W/s Glass Beading 1 1 2500.00 2500.00 - 2000.00 - Damaged
16 Wind Shiled Glass 1 1 8000.00 8000.00 - - 2600.00 Broken
17 Cabin Glass 1 1 2500.00 2500.00 - - 2200.00 Broken
18 Disposable Dash Board 1 0 40000.00 40000.00 - - - Disallowed
19 Key Board Angle And Key 1 0 16000.00 16000.00 - - - Disallowed
Board
20 Power Steering Tank 1 0 3000.00 3000.00 - - - Disallowed
21 Wiring Meterials Complete 1 0 7500.00 7500.00 - - - Disallowed
22 Air Cleaner 1 0 30000.00 30000.00 - - - Disallowed
23 Dash Bedding 1 0 6500.00 6500.00 - - - Disallowed
24 Front Main And Second Blade 1 0 3500.00 3500.00 - - - Old Broken
25 Bonnet Engine 1 0 5500.00 5500.00 - - - Old Broken
26 Radiator Water Tank 1 0 3500.00 3500.00 - - - Disallowed
27 Painting Charges 1 0 0.00 - - - - Disallowed
28 Disk Labour Charges 1 0 0.00 - - - - Disallowed
Total 223700.00 75159.00 9000.00 4800.00
Add CGST @14.00% 31318.00 10522.26 1260.00 672.00
Add SGST @14.00% 31318.00 10522.26 1260.00 672.00

Total 286336.00 96203.52 11520.00 6144.00

Less Dep @ 50.00% on Metal, 50.00% on Rub/Plast, 48101.76 5760.00 0.00
0.00% on Glass Parts
Total 48101.76 5760.00 6144.00

Total 60005.76

RECONDITION PARTS

S. Description of Parts Remarks Estimated Assessed

No. (Amt in `) (Amt in `)

1 Disposable Dash Board Disallowed 40000.00 0.00

Total 40000.00 0.00

 VN/2017/F/19 KA 02C XXXX Page 5 of 6

LABOUR CHARGES

S. Description of Labour Remarks Estimated Assessed

No. (Amt in `) (Amt in `)

1 Removing & refitting of Turbo Inter Damaged 4500.00 -

Cooler
2 Pulling & reshaping of Cabin Angles And Bent 26000.00 8000.00
M.s Sheets
3 Denting & Shaping of Cabin Tinkering Bent and twisted badly 24000.00 12000.00
Charges
4 Removing & refitting of Main Axle Bent Bent 3500.00 2500.00
Removing
5 Pulling & reshaping of Chassis Bent Bent 8000.00 5000.00
Removing
6 Removing & refitting of Mechanical Bend removing 6500.00 5500.00
Labour
7 Painting of Painting Charges Disallowed 12500.00 -
8 Removing & refitting of Disk Labour Disallowed 7500.00 -
Charges

Total 92500.00 33000.00

Add CGST @9.00% 8325.00 2970.00

Add SGST @9.00% 8325.00 2970.00

Grand Net/ Total 109150.00 38940.00

Summary of Estimate and Assessment of Loss

Estimated Assessed
(Amt in `) (Amt in `)

Total Cost of Parts 286336.00

Parts (Metal) 48101.76
Parts (Rub/Plast) 5760.00
Parts (Glass) 6144.00

286336.00 60005.76
Total Cost of Recondition Parts 40000.00 0.00

326336.00 60005.76
Net Labour Charges 109150.00 38940.00

TOTAL 435486.00 98945.76

Less Imposed Clause (-) 4000.00
Compulsory Deductable (-) 1000.00
Less Salvage (-) 4879.50
Add Towing Charges (+) 2000.00

TOTAL 435486.00 91066.26

Net Liability on Repair Basis 91066.26

TOTAL LOSS BASIS

New Value :

Current market value 650000.00

New Replacement Value : 650000.00

IDV :
VN/2017/F/19 KA 02C XXXX Page 6 of 6

IDV 400000.00

IDV : 400000.00

Net of Salvage from Total Loss Basis :

Value Assessed As Per Total Loss Basis : 400000.00

Wrecks value with RC 300000.00

300000.00

(-) Excess : 1000.00

Net Of Salvage Loss Liability ( From Total Loss Basis ) : 99000.00

Net of Salvage from Total Loss Basis :

Value Assessed As Per Total Loss Basis : 400000.00

Wrecks value without RC 250000.00
250000.00

(-) Excess : 1000.00

Net Of Salvage Loss Liability ( From Total Loss Basis ) : 149000.00

Cash Loss Basis :

Labour Metal Rub/Plast Glass

Estimate of 28400.00 53450.00 8200.00 2500.00

Total Excluding Tax : 53450.00 8200.00 2500.00

(-) Depreciation on Parts : 26725.00 4100.00 0.00

26725.00 4100.00 2500.00

Total Cost of Parts after Depreciation : 33325.00

(-) Salvage : 1500.00

(+) Labour : 28400.00

60225.00
(-) Deduction as per Cash Loss basis @ 25%
15056.00
(+) Towing Charges : 3000.00
(-) Excess : 1000.00

Net Assessed Loss as per Cash Loss Basis : 47169.00

Net Liability

Based On Details Provided Above, The Lowest Liability Under The Subject Policy Of Insurance Works
Out To ` 47,168.75

(ssued withour Prejudice)

SURVEYOR NAME
Insurance Surveyor & Loss Assessor