No.

129255
CEYLINCO INSURANCE PLC REPORT
"Ceylinco House", 69, Janadhipathi Mawatha, Colombo 01. Hotline: 2393939

ON THE SPOT LOSS ADJUSTMENT REPORT

Date & Time of Intimations: 02/05/2022

Claim No.: CLP400CF22000003 P P40009CF000036

P Policy No.:
Insured Name: Mr. . M.P.GUNASINGHA
Risk Location NO:1813 GUNASINGHA MOTORS PADAVI SRIPURA

Sum Insured: Building Stock in Trade

B'Wall Stock Held Trust

E. Installation Furniture
Machinery Equipment
Others Others
ConditionslWarranties Deductible/Excess
Reinstatement/Indemnity Financial Interest
Date & Time of intimation: 03/05/2022 Date & Time of Survey held: 03/05/2022
Amount of Claim: CST
Cause of Loss/Damage:
Underinsurance (average):
Deprecation:
Date & Time of Loss:

Description of Loss / Damage: Roof (Asbestos sheets: 9 nos. 12’ / Zn/Al sheets: 6 nos.8’)

Air compressor (V-0.25)/Monitor (LG/LX1751Q)/Welding plant/Electric motor

Claim Reserve: Claim Advance:

Further inspection place & date . Salvage: Deduct / Ignore / Collect

SPECIAL NOTES:
There is CST condition at this location and lightning situations also occurred. Therefore, some electrical equipment also got damaged. Zn/Al
structure is canopy structure. Therefore, insurer is not liable for that section.
For asbestos roof damages, OTS offer is Rs. 100,000/= subject to policy conditions, coverage and excess.
For electrical equipment damage, joint inspection is required.
In order to process the claim, detailed estimate and joint inspection are required.

0'

CLAIM ADJUSTMENT SUMMARY:

04/05/2022 Akila Wickramanayake

DATE NAME SIGNATURE OF LOSS ADJUSTER
(RUBBER STAMP)
DECLARATION (TO BE FILLED BY THE INSURED)
(1) I/We hereby confirm a representative from Ceylinco Insurance PLC. visited the location to inspect / survey & approval has been granted to repair /reinstate /
indemnify the loss, in accordance with the terms and conditions of the policy issued.

Date: ................................................ Name: .................................................. Signature: ............................................................

(With company rubber stamp)
N.I.C. No. .......................................................
(2) I am /We are in total agreement with the loss adjustment carried out at the above mentioned location. I/We also hereby expressly acknowledge having
received from Ceylinco Insurance PLC, a sum of Rs. ............................ Being the full & final settlement of my/our claim for the loss/damages

Date: ................................................ Name: .................................................. Signature: ............................................................

(With company rubber stamp)

(3) In consideration of the above settlement without producing of the Repair bills/Estimates/BOQ/Stocks record etc., we expressly undertake not to hold
Ceylinco Insurance PLC, responsible for any consequences of whatever nature which may arise as a result of setting the claim in the aforesaid manner and
further I/We undertake to submit all documents requested by Ceylinco insurance PLC..

Date: ................................................ Name: .................................................. Signature: ............................................................

(With company rubber stamp)