Annexure A -lnspection Report KIA Break Incase Renewals

Name of Customer Vehicle No

Address

Name of Dealer Inspection Place

Inspection Date Inspection Time

Recommended for Insurance Yes ( ) No ( )

Details of vehicle: (Please tick wherever applicable)

Safe Scratch Pressed Broken Old policy from Kia Program Yes / No

Front Bumper Chassis No

Grill Engine No

Head Lamp (LT/RT) Model-Variant

Side Turn Light (LT/RT) Colour

Indicator Light (LT/RT) Fuel Petrol Diesel | CNG/LPG

Fog Lamp (LT/RT) Yr of Manufacturing

Front Panel Odometer Reading in KM

Bonnet Electrical Accessories

Left Apron Stereo / Make

Right Apron CD Changer/ Make

Left Front Fender Any Other / Make

Left Front Door Non-Electrical Accessories

Left Rear Door Seat Covers

Left Pillar Front (A) Center Locking

Left Pillar Center (B) Any Other

Left Pillar Rear (Q Glasses Safe Broken

Left Running Board Front Wind Shield Glass

Left Qtr. Panel Left Front Door Glass

Boot Right Front Door Glass

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Rear Bumper Left Rear Door Glass

Tail Lamp (LT/RT) Right Rear Door Glass

Right Front Fender Rear Wind Shield Glass

Right Front Door Previous Insurance Details

Right Rear Door Insurance Company

Right Pillar Front (A) Policy Number

Right Pillar Center (B) Expiry Date

Right Pillar Rear (Q No. of Claims

Right Running Board Time Lapse

Right Qtr. Panel Reg. Certificate Shown Yes No

Door/ Silencer Engine Starting Condition Yes No

FT View Mirror (LT/RT) AC Compressor Working Yes No

Tyres / Rim CNG / LPG Fitted Yes No

Declaration of owner : I hereby confirm ad declare that above mentioned identification of my vehicle
as well as that of damage to the vehicle as noted by the inspection official is correct. Nothing has
been hidden / undisclosed. I further confirm and declare that the motor vehicle proposed for
insurance after a break in cover has not met with any accident giving rise to any claim by a third
party for injury or death caused to any person or damages to any property/insured vehicle during
the period following the expiry of the previous insurance, till the moment it is proposed for insurance.

I also agree that damages mentioned above shall be excluded / adjusted in the event of any claim
being lodged.

Seal of the
Name & Sign of Proposer ................ .. .................... ... ................... ... ........... Dealer

Name & Sign of Surveyor / Dealer Authorised Person ......... ........................

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 VEHICLE INSPECTION PHOTOS WITH TIME STAMP (Date, Time and GPS Location)

FRONT SIDE OF THE VEHICLE

BACK SIDE OF THE VEHICLE

(ALONG WITH VEHICLE NO)

(ALONG WITH VEHICLE NO)

RIGHT SIDE OF THE VEHICLE

LEFT SIDE OF THE VEHICLE

(ALONG WITH VEHICLE NO)

(ALONG WITH VEHICLE NO)

Seal of the
Please Note : Without Timestamp on the Photos, Proposal will not be accepted for Break in cases.
Dealer

Name & SIgn of Surveyor / Dealer Authorised Person ................. ................................... ...................................

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 VEHICLE INSPECTION PHOTOS WITH TIME STAMP (Date, Time and GPS Location)

SPEEDOMETER OF THE VEHICLE

ENGINE / CHASSIS NO PHOTO

ALONG WITH THE VIN NUMBER

PREVIOUS POLICY COPY

R C COPY (FRONT AND BACK) / RENEWAL NOTICE

IF NCB IS GIVEN

Seal of the
Please Note : if any of the Parts damaged noticed during inspection, please take separate photo Dealer
and attach along with the report., please share the RC Copy and Previous Year Policy Copy.

In case of Commercial Vehicle (Taxis) – Vehicle Fitness / Permit has to be attached for all the cases,

Name & SIgn of Surveyor / Dealer Authorised Person ................. ...................................

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 NO Claim Bonus - Declaration
“I / We declare that the rate of NCB claimed by me/us is correct and that no claim
as arisen in the expiring policy period (copy of the policy enclosed). I/We further
undertake that if this declaration is found to be incorrect, all benefits under the
policy in respect of Section I of the Policy will stand forfeited.”

NAME OF THE INSURED: _________________________________

Vehicle Registration No: ___________________________________

Make and Model: __________ ______________________________

Previous Year Policy No. ___________________________________

Previous Insurance Co ______________ Expiry Date: ___________

Percentage of NO Claim Bonus earned / if any: ________________

Claim Experience: ________________________________________

Date:
SIGNATURE OF THE INSURED

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