GSTIN: 090PBPS0937E1ZJ Mob.: 76076 63198 M/s. ANCHAL GREEN (AUTO PARTS) TWO lac Suede Date Job No Customer's Name Address Thwalaran. want. Aloe panes SUBJECT : ESTIMATE OF REPAIRS As Desired by you we submit herein our estimate in Duplicate to be/b OTEQS\ DESCRIPTION OF WORK Days will be required after ‘Confirmation. mn appoximation, We Shall Proceed for [_rorat | 40cce[ 4 See eur annanalans eo ARISoa ae ‘This estimate is only repairs as per condition: Gaanp ToTaL | oow | J Supplimentary estimate may be issued Reajred) Vehicle Checked by Service Engineer/Manager TERM & CONDITIONS APPROVED 4. Party will pay 50% amount in advanced ofthe total amount of estimate, 2. Subject to conditions overleaf, Customer's SignatureMOTOR CLAIM FORM IFFCO TOKIO GENERAL INSURANCE COMPANY LTD. fice: IFFCO SADAN, C-1 Distt. Centre, Saket, New Delhi-110017 IF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABI Ty, ANSWER ALL RELEVANT QUESTIONS FULL i spce ound isficeplae atch spurl shos OWING ORIGINAL DOCUMENTS (AS PeaaE coe (AS WELL AS PHOTO COPIES) AT THE TIME OF A) Esimate of Repairs 8) Registration Gorttioate ©) Diving Licence D) EIR, It Applicable SOVER NOTE / POLICY NO.__ LT |S606%4% cLaim No. Policy Period From olfiel To el esjeag 4, INSURED (a) Name (b) Address for correspondence : Vista Tnudes! (c) Occupation : (d) Telephone / Mobile No. : Sraso04a at (©) Email 2. ‘THE INSURED VEHICLE MAKE YEAR OF ENGINE NO. ‘CHASSIS NO. REGISTRATION NO. MANUFACTURE Hyandat Jere searse| 076234 Mpogczs7 és (A) (__ Was the vehicle in proper working condition = Yes (i) For what purpose was the vehicle being used at the time of accident ? (ii) No. of Occupants & their Names 4 Sanlosh kamen Ren} (8) Additional Information for Commercial Vehicles Only {e) _ Nature of goods carried (b) Unladen weight = (d) Nature of permit: (f) Was the vehicle plying for hire?: (g) _ No. of passengers carried :__aifa_~ (h) No. of passengers permit: WA (a) Registered laden weight (©) Weight of goods carried 3, DRIVER AT THE TIME OF ACCIDENT (@) Name tye (c) Address ae mn (@)_ Isthe Driver : 7. Owner 2. Paid driver 7 2 Ne 3. Owner's relative o* friend 4. Relationship with the owner > If paid driver, how long has been in your employment? io We he under the inuencs of intoxicating liquor or drugs? (a) __ Driving Licence Number a (h)__lesung autoity Date iry “Type of vehicles authorised to drive k) ‘Was the licence temporary / permat (i) Has he been involved in any accidé(e) cu FAILS OF ACCIDENT/ INCEDENT Besa) oo fo2 | pet te Place Give a descriptian of the aceident wa ve ns LATER tot If any third party was responsible for the accident ee give name and address ‘Was any intimation given to police? If yes, FIR No.& Dt. Nila 5. DAMAGE TO INSURED / VEHICLE (a) (b) (o) Eull details of damage + ER Biangen , Fenel ati4 Side» Hicror- Estimated cost of repairs {Ou \When and whore can damoged veil be ispectd? | Actas SMASH -gtcsiad Quebec &. THIRD PARTY INJURY / PROPERTY DAMAGE, (@) (b) (c) (d) (e) (fy (0. Name of injured = wa (i) Occupation : (ii) Relation with insured =) Address: Ala. Full details of personal injury sustained : MA Name and address of any person / hospital wa given medical attention to injured person : Full details of property damaged: Ag Has notice of any claim been given to you? : wla 7. INJURY TO DRIVER | OCCUPANT Was dtiver any cocupant injured? WA fa) (b) _ If yes, give full details: Ava : 8. THEFT. rl (a) Date: (b) Time = (4) _ Item stolen? : (e) Estimated cost of replacement: () Has theft been reported to Police?: (9) FIR Number & Date (Pls. attach Copy of FIR): best of my /¢ 1 / We the above named, do hereby, to the be foregoing statement in every respect, and |e Ste may require in respect : bs suppression or concealment the Poly shal Be ¥24 future accidents shall be forfeited. Dateoe Date of 265 Net Chassis NumberPY JNPLLIRS. TWA BAZAR Bans ROAD DOH ARTI PRADESH (State Cae) c86 Corer Ls, 199) WT IRDA Reg ot Propoal Na & Da revi Pots Nas Preis are: The Now Inds Ase Copan init. ParodfOwaDamages_0-0C1-2123 (os to 30SEP-2024(1 YEAR) Pato fatty Cres 01-OCT-2025 (0) Te 30-SEP 2001 YEAR) Paved compat, enol Acct Caer Ta RSENS (1-0€12023 (00) To 3 SE2004 (YEAR) 2oonRKiR IM csr emia Dea Na Aware) aa Tene ae Ca Moonta Var Se Deir pe Regatraton Ne RTO. Tipeienoeaaae Tat iNcaeaieN THATCHDAGE MPOU CZ ses Bistro Actors Ten iriat Acca Tit Tol Dy age “amas 04s - Cas bamag Pain Dia KAM 25) ‘Seb Total (Be Prema) otuy Douce) (MT: 22A) ‘An The Dosee (IMT) AA Monte (ME) No Chin Dens (%) Handcapped Deca (DMT-2) Sab Total (Deductiin) ‘Abs On Coverages (2D, C4. EP, RE, KF, PE) ‘NetOws Damage Premium (A) ai-on Caner Opt im te Pos 7a Dosa DANI TOGRTSTOTTRBTIY Cons ae Tati eae 7 a 658, Dito Ke GngapticalAc stcoe (BT) Sob Total Tin Party ity) ‘Comply PA Cover Owes Diver Re 50000 (M15). PA Cove Unnamed Pass Rs 0000 Esk OMT 6) (968 PA coer for Pu Dro Re Lae M1) ag inaty Paid Dvr 3H) epee Gr Opn) (FI) ‘Sab ata (Leptin) Sot Lis Prete (B) “oll Premio (A88) ‘6 sest199) TST ARNT ag Ba TSAR pat oatPocosvo sono nd, oV0 24399) oun vsoRDANOGANISVOI20010, Key Pc RDAN IORI VOIBODUAWVORES) Penal Blog DANI Dea $¥0120010. ce hs pays ac ad pe ded ye red ta Polson dy Cal UC) Cons a ae aerate hy tac ianad obvi von alanine POX de Se Crea pple Ong ain Scigatasees oe oe 1 Policy eae jet ens oa pa a ee AS 7 Tit pig hw ed nonin ni lig arog TAC oa Se Sa ae ec =o eran a oe eos cee tar cece Fe aT ft TOE OPE OO eye de cerned reo eerste atone econo ae ‘arOvacr Dive Is ate ro dane tie ot oy in ad ei ting ie ping ye) 20% reg aur tavosne yan Rss Ove cnn Jats sea OD Prin nas mean gree move od der ata) Gerace Caen For onon ny gry a pre our oy Sircpn gts sy beets Fant Sori tyes fer Nor Velie arms Savion, Fee S098); MADHYA PRADESH C2 “ See ee ee ans cae of eum: we na a nas ih isurace Broker Name: Hyenda dls Insrone Broking Pv i [sarc ck Fee tg Noa, DLE Cer, Phase arseeee gr tt Deepak Kumar Soni ‘oH fAf/DOB: 25/02/1988 ‘gPe/ MALE g 3 i 5 9263 8765 |_____ ae sven, a wea id ‘Bere weet - 272192 Address: E S/O: Raj Prasad Soni, bansi road, itwa,