Report No.

: XXXX Date : XXXX

UII/OIC/NIC/NIA FILE NO: NIL MOTOR [SPOT] SURVEY REPORT
This report is issued 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: xxxxxxxxxxxxxxxxxxxxx CLAIM NO: To be alloted.
VALIDITY PERIOD NIL / Nomal Dep IMT 23- Y
INSURER :
INSURED : Mr. Mohan Kumar Shaw
FINANCIER:
VEHICLE PARTICULARS :
Registration No: xxxxxxx Class of vehicle:
Date of registration: xxxxxxx Type of Body:
Chassis No: Seating capacity:
Engine No: R.L.W:
Make & Model: xxxxxxxxxxxxxxxxxxxxx U.L.W:
Permit No: Route Area:
Permit Validity Type of Permit:
Tax Token No: Fitness Validity:
Tax Validity: IDV: Rs.
DRIVING LICENCE PARTICULARS :
Name Licence No.
Address Date of Issue:
Valid Upto:
Class / Type Issued by:
Load challan.
POLICE ACTION:
Date & Time of Accident: Date of Allotment:
Place of Accident: Date of survey:
Representative Mr. Place of survey:
DETAILS OF TPPI /TPPD: As per declaration of the Insured neither any personal injury sustained nor any third party property was
damaged.
SURVEY DETAILS: Acting under the instructions received from .......................... to conduct spot survey of the above accident, the
undersigned visited the place of accident and completed the assigned job on 00.00.2021. The captioned was shifted from the spot and kept
at the side of the road in the same condition as shown in the photographs.

CAUSE AND NATURE OF ACCIDENT: Based on the discussion with the insured's/representative/driver it could be revealed that the
loaded/empty vehicle while moving towards ................ from .................. met with an accident near ..................on 00.00.2021 at about
00.00 A.M./P.M. At the spot ........................................................................... Resulting the insured's vehicle sustained damage. The extent
of damages noticed on the vehicle are consistent with the circumstances of the accident.

PARTICULARS OF DAMAGE :
NOTE:- The Insured/Insured’s representative was requested (1) To protect the damage vehicle from further loss and any inter change of
parts/units. (2) To submit Estimate to the Insurer without dismantling the vehicle.
1) Utmost care has been taken to note all the visual damages. Existent but non-visible damages may be considered at the time of Final
Survey. 2)Due to non receipt of documents from the Insured (Sized by police authority) the preparation and submission of report has
delayed. The Insured/Insured’s representative was requested (1) To protect the damage
The damages sustained by the vehicle were found concurrent to the cause and nature of the accident.
Documents to be Verified: (a) Regn. Cert. (b) Driving License (c) Tax Token (d) Route permit.
This concludes my spot survey report. We have received the survey fees for service rendered from Insured’s representative and gave him
our bill.
This concludes my spot survey report and the complete claim file are returned along with my survey fees bill for service rendered.

NOTE:- Utmost care has been taken to note all the visual damages. Existent but non-visible damages may be considered at the
time of Final Survey. The damages sustained by the vehicle were found concurrent to the cause and nature of the accident.

DOCUMENTS TO BE VERIFIED : (a) R. C. Book (b) Tax Token (c ) D.L. (d) Fitness Certificate (e) Permit
This concludes my report and the complete claim file are returned along with my survey fees bill for service rendered.

RATHINDRA NATH PATTANAYAK

(SURVEYOR)

RATHINDRA NATH PATTANAYAK

Report No. :
Right half of the cowl found badly damaged.
Electricals: The left side headlight found broken. The wiring harness front portion found choped at several places. The
battery Local Make found cracked and the electrolyte found leaked out.
Cooling system: The radiator found badly damaged. After dismantling the radiator core and also the water tanks found
pressed & bend. The fan found broken. The water pump body found cracked and pulley found bend. The water pump found not working
properly. The air cleaner found pressed.
Stearing system: The steering wheel found bend. Steering bracket & Steering rod bend. On dismantling the steering
box the sector shaft and the steering worm pinion found damaged. The steering linkages i.e. drug link, tie-rod and steering arms found
bend. Engine Assy: The timing pinion cover and the housing found broken. The engine found moved / uprooted
from the engine mountings. Fuel pump bearing number Q97236228 found badly damaged. An estimate for the fuel pump was obtained
from M/S Super Diesels. Chassis: After dismantling the cabin and lifting the load body, both the chassis long members found
badly damaged / bend. Front cross-member found badly bend. After striping out the chassis the long both members found badly bend.
Brake system & Suspension: Hand brake system found badly damaged. The hand brake isolator found
damaged. The spring leaves found broken as detailed in the assessment.
Front axle: From the spot photographs it is observed that the front axle of the vehicle detached from its original
position and moved back. On dismantling the front axle the I beam found bend and misaligned.
NOTE:- The Insured/Insured’s representative was requested (1) To protect the damage vehicle from further loss and any inter
change of parts/units. (2) To submit Estimate to the Insurer without dismantling the vehicle.

RATHIN PATTANAYAK
RATHINDRA NATH PATTANAYAK
Telefax: (033)2679-2189
SURVEYOR / LOSS ASSESSOR.
Mobile : 9830184200 / 9434129236
(MOTOR-B, MARINE CARGO-C, ENG-C MECHANICAL ENGINEER) Office : Axis Bank ATM Building (Gr. Floor),
LICENCE NO:- SLA-27364, Dt. Of Expiry-11.03.2020 S. N. Bose Road, Sankrail Chapatala, Howrah –711313.

TO: RO. KOLKATA Survey Report Ref. No.: MT-483/18-19 3/4/2019

Claim Ref. No.: 310011/31/2019/032397
As per your instruction vide mail dated 27.02.2019 I have carried out the Final Survey of the damaged vehicle and
submit my Preliminary Survey Report as under:-
SR. NO PARTICULARS
1 POLICY ISSUING OFFICE Oriental Insurance co. Ltd, Kalyani
2 INSURED MD. YUSUF AND MD. MUSA
3 VEHICLE NO WB 37A 6766
4 ENGINE NO 40M62376259
5 CHASSIS NO 426021MVZ215339
6 DATE OF ACCIDENT 12.02.2019
7 DRIVER'S NAME MD. YUSUF
8 DRIVING LICENCE NO. WB5920050028443
9 DATE OF SURVEY 27.02.2019
10 IDV OF VEHICLE
11 AMOUNT CLAIM (ESTIMATE) Rs-432000/-
12 APPROX LOSS/LIABILITY Rs.240000/-
13 THIRTY PARTY LOSS IF INY NO
As per intimation letter the vehicle dashed at the road side tree to save a buffelo.
14 CAUSE OF ACCIDENT
15 DESC RIPTION OF DAMAGES Cabin l/s found smashed, dashboard l/s smashed, load body-l/s front
portion body damaged, wooden cross member broken, chasis frame body bend, front suspension, I beam detached
from chasis and move back, damaging under chasis components, cooling system- fan, radiator, air cleaner damaged
electrical- wiring, battery, alternator, self starter daamged, pipes, brake pipes, diesel pipes, Mobil chamber found
damaged. Photoghraphs taken attached for observation & record.

15 REMARKS, IF ANY The preliniary inspection done on 27/2/19 and advised insured to inform me after
dismantling before starting the repairing job.
Rathindra nath Pattanayak.
(Gr. Floor),
 TAX INVOICE
RATHINDRANATH PATTANAYAK email- rathinpattanayak@yahoo.com
Govt. License No. SLA-27364 È : 9830184200 / 9434129236
Date of Expiry-11.03.2023 Office : Sankrail Chapatala,
Pan No: AEOPP9134Q CESC Cash office (Gr. floor)
GSTIN -19AEOPP9134Q1ZD Howrah-711313.
ID CODE:

0
0
INSURED : Mr. Mohan Kumar Shaw
POLICY NO: xxxxxxxxxxxxxxxxxxxxx
CLAIM NO. To be alloted.
VEHICLE NO. xxxxxxx xxxxxxxxxxxxxxxxxxxxx
Date & Time of Accident: RS. P
Professional fees. (Spot Survey-Aprox Estimate - Rs.---------/-)

Conveyance to …………...at ……………..(Kolkata) & back by own car no WB-

12AB-2353 on ………………………. Total 0 days @ Rs.600/day
Halt age. Full Day on 00.00.2020 @ @ Rs. 750/-
Half Day on 00.00.2020 @ Rs. 375/-
Less than half Day on 00.00.2020 @ 30% on full day.
Photographs. (Digital) 0 Copies @ Rs. 10/- each. 0.00
Postage Charges.
Amount before tax 0.00
Taxable value Rate CGST SGST Total Tax Amount IGST @ 9% 0.00
0.00 9% 0.00 0.00 0.00 SGST @ 9% 0.00
HSN Rounded Off(+)(-)
CODE:997162
Grand Total 0.00
Bank Details:- AXIS BANK LTD, SANKRAIL BRANCH
A/C -909010033276022 IFS CODE-UTIB0003970
Report No. : XXXX E. & O. E
Invoice No: XXXX
Date : XXXX
RATHINDRANATH PATTANAYAK

CONVEYANCE EXPENSES REVISED SURVEY FEES

A CLASS CITY - 600/- ESTIMATE OF REPAIRERS (Rs.)
OTHER PLACES - 350/- UPTO 20,000/- 850/-
20,000/- TO 50,000/- 1200/-
CAR - @ 15% of petrol 50,000/- TO 100,000/- 1500/-
price per km 100,000/- TO 200,000/- 2300/-
 ABOVE-2,00,000/- Rs. 2300/- + .7% on balance
amount of Rs. 2,00,000/-
2,00,001/- TO 5,00,001 subject to maximun of Rs.
5,00,001/- TO 10,00,001 120000/-
ABOVE-10,00,000/-

RE-INSPECTION & SPOT SURVEY

UPTO 80 KMS 850/-
ABOVE 80 KMS 1200/-
UNITED INDIA INSURANCE CO. - GSTN NO:-19AAACU5552C1ZG
NATIONAL INSURANCE CO. GSTN NO:-19AAACN9967E1Z0
NEW INDIA ASSURANCE CO. GSTN NO:-19AAACN4165C1ZO
ORIENTAL INSURANCE CO. LTD GSTN NO:-19AAACT0627R3ZU
ORIENTAL INSURANCE ID CODE – GH0000046035
NEW INDIA ID CODE- 1D12127620
OFFICE

NIA ID CODE-1D12127620

OIC ID CODE – GH0000046035

NIC ID CODE-95303932