HIMALAYAN EVEREST INSURANCE LTD.

Thapagaun, GPO Box ' 148, Kathmandu,,Nepal

Himalayan Everest 977''l -5245099
Tel: 5245090, Fax:
website: www.hei-com.np,E-mail: saru 'sh resth a@hei 'com 'n p

D"te. .. . P.'t.[P.Q].?D-??

ur.i Messrs..KIShl9 Bro<od Q"'

Re: - Claim No.:-

policy No. :- ..gqTl Py1 rll ?. -"-l?e...1'p.q.9 ?9.........Endorsement No' : -" " " " "'
Loss /damage toB6u.9.i..<.Ht-e .*f:.$:.{d[9 . * ?'9.8..q.]9il]]'at /'"ar"Kqng)Pg
' tfz
rnsured:-.t{r\\Kif.q$l...BJ.K1C...BgnK..l,lE}....ft1c..(s.f:...N].U.1h..fxc\cte.'f')}er.n.Srfi.P.5'ql"Py}
qt52g?Sqjt I Skqorn:oc) \< nrohot')
( ontact numoer :- ...;,. .--. '. . .. ...

are appointed to conduct thorough survey cum assessment ofthe loss

with reference to above claim, you
at your earliest.

The following points please be noted for your compliance:

LOSS is not available instantly, please advise insured to submit the same
to us
1. If ESTIMATED
under copy to you immediately for our attention'

2. please submit us your Survey Report within 15 days. In case you are unable to submit.your report
the
*ftfrf" .iiprf""a iim", pl"ase issue an interim report on the claim status at interval assigning
valid reason.

). In case oftoken, we request you not to get it signqd'

4. In case ofTP involved please assess separate sheet as oD basis for knock for knock recovery'

5. Further, iflnsured intends to withdraw the claim, please obtain Insured's

written consent and
forward the same along with your comment for our attention'

on PAN/VAT bills.

Shreslha
Assistant
Departn€&0ior

CC: (Concerned Branch/Marketing office0.... '\J'\ilel{C0" " S'hf('qL\q" " " " " " " "'for information'
 Head Office : Thapagaun, GPo Box' 148'
Kath andu' Nepal

HimalaYan Everest Tet No. : 5245090, Fax :5245099

ktm@hei.com.np' lYww'hei'com'np
lrTsurance Limited Email:

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sAr rKl-rl1oth (-3iKqs Bon\< 9.0- l.?P ?.. 3
q, q' oli. r-.ruf l. l rrqc\ e ^f-nk{nafi
prql o ute, 0?.1
.

Bqls.Qs'i"rl.. ..?,. .l(gll$sl+u..'

Dear Sir/s, Madam

to ubou" und regret to note the same'

iuiJ in. Clain Form duly completed
-r.n*d "n.tot.a

A. FOR OWN DAMAGE CLAIM:

"'-*"Ertirnot"/Q*totionf rom-theauthorizeddealerirepairer'
-t', -/?.oov of Drirn ', oriur,g ii"i;''"ii-"ia*"a vgii-c1e.nesr.*mtnn Book (Blue Book)'
{ i;i;"" ;;;iirii"u' ir i1i"ote (comm.e rci .veh.i cte on tv)
Police authorlty'
d-'Originat Repar, from the concemed
-j)iriZi"^tiirBills/CashMemostowardsrepair/replacement'

B,
H T.P. Vehicle
a) Iniurv /Death j: E fiffiton fron rhe authorized dealerh'epaiter'
l. Police RePort.
- crii ,ibinr* Driving Licence, Registrution
vehicle
i.'
,i.E^;;cr;A Card issued bv the treating Hospitau nii* inu" sook) & Riute pernit (if applicable)'
Nursing home
'i."iiillia'lri'i*rr's/Hospitat's pres*iptions/t'{urse's
"i"ii i""iru o""or's piescriprion including chit tirifii'vli n ls/Cash Menos towarcls repair /
';i. ':j!3-L"',fll
replacement
issued bv the Nutse on dutY'
5. Third Party PolicY CoPies
4. Disciorge Sumnn4t in origiml'
expettses
5. Originalbitls incurred Jbr medical
tegat authoritv'
;;;:;;:;'";;';fr;*i o'iginot done tn presence of the concerned
i'
q@ slv6l FAqr :
ql qtffiq vt dzn qel
cft7tq qfuAfi (PostMortemReport)S{41'
fu'wmm'ar'
d w
f,qf'iln afiqftat t
q) YilfrTn lkn Yrtttt Ytr ( Certilicate of rel ationshi P)'
rfitrd .rt t{r Ir$ c+
sRfu* +rqqr{6{ ffi( sr?-6 arq"sfrffi ffi q-fr6 dm qt{-qd

Mr. /tr4/s..Kh*hnn..Plt..ft8+C'
been deputed for surveY and t!9s

Yours faithfullY,

Encl: Claim Form. and to conduct survey'

CC: MrMs. . . . . .. " " "'for information
""'"" (H o'/B'o') for information and coordination'
cc: Mr................'....""""..'..""""..
 Verble !ntimation Form
(To be filled by HEI staff in case of intimation of Loss verhally)
Mode : Yftelephone I Personally
Date lq.- 2-2oQo Time 8. Do (it4
Telephone No Mobile No : gSs1.olsg3?
Intimated by !L.r-or,rkq r(uvrro"t UohaPo

Particulars
Insured Name N{uhH^M-er,\Ur Aoarc bJ- qc
^4uli
6t
f 34:
Type ofpolicy
llprl Pvllll!212s \ (If have) Tag No 'l-n)+r duttiztlel PW
:
oh \r ?,n
Policy No.
Lp-q'l pvl u I r-il 2r lno !r o
olicy Period l From : fg llr_lrar_r I
To tslg-llzoL,t
Incident details
Date of illness

Place of incident IClt-"lptr y'

Cause/ Disease : (If have) No. of Loss

Date of Loss t6-sL- 2-o&o Death / Non-Productivity /Loss

Estimate of Loss (Capital Sum Insured )

Advised :

tn provide letter / written [ ] Tu frrudde- c\aih^ 'knUnrnl,ian arrJ $trova*iot1.

olhers ifany :

i
Name of attendant : Nh'/^crhloh eh i('-,.")3
\52
r
I
Signature of attendant
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UNITED AUTO RN PVT LTD
BHARA'IPUR- I O. HAKIMCHWO
056-5)6842 ncernsparepartsgmail.com

DATET 2O8O/02/24
QUOTATION-RN-075
7 JUNE,2O?.2
179-8O
NAME: GS MULTITRADE INTERNATIONAL PVT LTD i9855029540)

REGD NO: BAG PRA 01 026 CHA 7235

VIN NO: ME EH 8C002M8O24674

INSURANCE COMPANY:

PA!IT.C I!AiVIE QTY AMOUNT

lPCS isoooo
lPCS 43s.00
1PCs L4,500.00
lPCS 7,4s0.00
lPCS s,200.00
lPCS 12,500.00

MIRROR ASSY RHS l PCS 17,500.00

FENDER LINING RHs lPCS 7,450.00

MONOGRAM RHS l PCS 2,250.00

WHEEL CAP RHS lPCS 350.00

lPCS 21,500.00
2PCS 3,500.00
CHARG E 6,500.00
9,500.00
28,500.00
1,500.00
1,000.00
UNTTED AUTO CO]\CERN PVT LTD
BTI ARAI'PI., R- I O. II^KIM('I I\\ OK
05 6-s26842 unil dautoconcernsp{ repa rlsgma il.com

lN WORDS: - RS.ONE IAKH FOURTY EIGHT THOUSA ,D FOUR HUNDRED EIGHTY FIVE RUPEES ONLY/-

NOTE: - l.Above rates are inclusive of 13% vat.

2. Valid for 30days.
3. More parts and labor charges may vary !. hile the time of repair.
4. Kindly collect old or replaced parts withir, 7 days after the delivery of vehicle hence
after the service centre will not be liable for those parts.

PREPARED BY INSURANCE SURVEYOR

SHARU BASNET NAME
STORE INCHARGE CONT,NO:
UNITED AUTO CONCERN PVT LTD