9045559710, 9559571425

DHEERAJ PANDEY 88, BHARDWAJI MANDI,

Govt. Approved Surveyor MUNNU GANJ PHATAK
(SLA 121928 Validity 12 Jan. 2024) dheeraj2228889@gmail.com Shahjahanpur - 242001

28-05-2022

MOTOR SURVEY REPORT (SPOT)

This report is issued by me as licensed Surveyor without prejudice, in respect of cause, nature and
extent of loss/damages and subject to the terms and conditions of the Insurance Policy:

Policy No. 42040731210100000691 Insurance Co’s

Period of insurance 04-07-2021 to 03-07-2022 Claim No.
1. INSURERS : The New India Assurance Co. Ltd.,
(Address) Shahjahanpur

2. INSURED : Ajay Pal Singh

(Address) Plot No. 9 Sonia Nagar, Keshari Kheda, Lucknow

3. Financiers, if any : Nil

4. VEHICLE PARTICULARS To be verified, Noted from Xerox

(a) Registration No. : UP32GN 1236
(b) Registered owner : Ajay Pal Singh
(c) Date of Registration : 05-07-2016
(d) Chassis No : 12646
(e) Engine No : 16508
(f) Make/Model : Tata LPT 909/2016
(g) Type of body : Open Body
(h) Class of vehicle (use) : Goods Carrier
(j) Pre-accident condition : Satisfactory
(k) Registered laden weight : 10550 Kgs.
(l) Un-laden weight : 3813 Kgs.
(m) Fitness No./Validity : 11-07-2023
(n) Seating capacity : 3 in all
(o) Road tax paid up to : 31-05-2022

5- PERMIT PARTICULARS To be verified, Noted from Xerox

(a) Permit No : UP2021-GP-4148B
(b) Name of holder : Ajay Pal Singh
(c) Valid up to : 03-08-2026
(d) Type of permit : Permanent
(e) Area of operation : All UP

6- ACCIDENT
(a) Date & time of accident : 26-05-2022 at 02:00 AM
(b) Place of accident : Near Vill.- Murchha, Powayan Rd, Sindhouli, Shahjahanpur
(c) Date of survey : 26-05-2022
Contd…...2

2
Report Dheeraj Pandey Contd…
7- DRIVER PARTICULARS To be verified, Noted from Xerox
(a) Name : Pawan Kumar Yadav
(b) No. : UP35 20110015023
(c) Date of issue : 18-01-2021
(d) Valid up to : 18-11-2031 (NT), 17-01-2026 (T)
(e) Issuing authority : LA Unnao
(f) Type of license : LMV+M/Cycle Only
(g) Endorsement : Trans w. e. f. 16-01-2018

8- MISC. INFORMATIONS
(a) Passengers at the time of accident
(b) Injuries to driver/occupant
(c) Police report
(d) T.P. involvement/loss
: Vehicle was Parked
: No/Nil
: Not Lodged till spot, advised to lodge the same
: An Unknown Truck, No. couldn’t traced/Nil

9- LOAD BEING CARRIED : Loaded with Pesticides

Ex. Lucknow to Shahjahanpur
GR Not Produced/to be verified

10- CAUSE-NATURE OF ACCIDENT : As told by the driver that said vehicle was parked at
roadside, suddenly an unknown truck hit at front and thus it
sustained damages.

11- OBSERVATIONS

A) Registration/DL/Permit/Fitness/GR particulars to be verified/as produced. Chassis

number physically verified.

B) Soon after having instructions from office on 26-05-2022, the undersigned made a
visit to site, Near Vill- Murchha, PS- Sindhauli, Powayan Rd at Shahjahanpur and
carried out the inspection, in reported condition. The loss and circumstances were
discussed with driver, necessary photographs were also arranged to visualize the
extent of damages, which are self explanatory, enclosed herewith.

C) After weighing all sort of evidences/physical verification of damages, I opine that

questioned vehicle sustained accidental damages, resultant to reported
circumstances and also looking very fresh.

LOSS SUSTAINED TO THE INSURED’S VEHICLE NO. UP32GN 1236

Fr Show Panel heavily pressed/Grill broken, Inner Structure Bent. Fr Bumper pressed.
Both Bumper high beam light broken. W/S glass broken/frame pressed. Fr Both doors heavily
pressed/Trim broken/glass machine bent. Cabin disalign/All joints strained. Cabin Roof/Rear
Structure upset. Cowl Top Garnish Broken. Wiper Arm bent. L/side Head Light broken. Entire
dashboard upset/broken at joints. Radiator/Hoses heavily pressed. Engine & sub-assemblies
Intact/Mountings to be check. Chassis L/Side longitudinal member bent. Steering Column to be
check/L-Side Tie Rod Assy bent. L-Sides Leaf Spring/U&C Joints may bent. Air Filter Body
Broken. Ignition not working. Wiring dislocated/Cut. Battery Intact.
The insured was advised to remove the vehicle from site and inform to insurance Co. before any
further repair. These are the only visible damages observed by me while inspecting the vehicle at
the spot of accident. If any other internal part comes into light at the time of final survey, same
may be considered in the light of cause and nature of accident

Encl. Your’s truly

1-Fees Bill
2-Photographs - 08 digital
3-Xerox of RC/DL/Permit/Fitness
(DHEERAJ PANDEY)
 9045559710, 9559571425
DHEERAJ PANDEY 88, BHARDWAJI MANDI,
Govt. Approved Surveyor MUNNU GANJ PHATAK
(SLA 121928 Validity 12 Jan. 2024) dheeraj2228889@gmail.com Shahjahanpur - 242001

FEE BILL
Bill No. NIA/5/2022 Date- 28-05-2022

To,
The Manager
……………………………………………
The New India Assurance Co. Ltd.
……………………………………………
Shahjahanpur
……………………………………………

Re: Claim Number

Policy/Cover Note Number 42040731210100000691
Pertaining to UP32GN 1236
A/C Ajay Pal Singh
Recipient GST No.
--------------------------------------------------

1. Survey fees on Spot . Rs. 850.00

2. Photographs 08 No. @ 10/- Rs. 80.00

2. Conveyance 38 KM by Bike @ 7.5/- (both sides) Rs. 285.00

3. DA 30% Rs. 250.00

-
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TOTAL Rs. 1465.00
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(DHEERAJ PANDEY)

_____________________________________________________________________________________
PAN NUMBER CQAPP6081J, A/C No. 20070091746, SBI CHOWK MANDI
MICR 242002004, IFSC SBIN0004000